Healthcare Errors

Healthcare Errors Error is defined as the failure of a planned

action to be completed as intended or the use of a wrong plan to achieve an aim. By IOM

Healthcare ErrorsErrors or mistakes committed by health

professionals which result in harm to the patient. They include errors in diagnosis (DIAGNOSTIC ERRORS), errors in the administration of drugs and other medications (MEDICATION ERRORS) and errors in the performance of surgical procedures,,etc

MEDICAL ERRORS are differentiated from MALPRACTICE in that the former are regarded as honest mistakes or accidents while the latter is the result of negligence,

reprehensible ignorance, or criminal intent.

Causes

•Poor doctor handwriting

•Poor doctor instructions

•Failure or delay of patent to report symptoms and medications.

•Failure to report other alternative medicines they are taking

•Non-compliance of patient with treatment plan

•Fear of legal issues: e.g. failure to admit to taking illicit drugs

•Fear of social issues: e.g. failure to admit to lifestyle or social habits.

•Fear of doctor's scolding: e.g. failure to admit to not following treatments.

•Patient pressure: the tendency to push the doctor for certain treatments

•Failure to read medication labels and instructions fully

•Wrong medication dispensed

•Similarly labeled or packaged medications wrongly given.

•Similarly named medications confused (by doctor or pharmacist)

•Wrong dosage dispensed •Failure to communicate instructions on taking

medication •Nosocomial infections•Wrong patient surgery •Wrong site surgery: e.g. surgery on the wrong

organ

Results of Healthcare Errors

Fatal errors could lead to patient's deathErrors may make the patient worseBad Reputation of the hospital and medical

staffWasting of time , effort and moneyMisdiagnosis of diseases

WHAT IF an ERROR HAPPENED !!!“7 Steps”

1. CARE: Take Care of the PatienT Address Current Health Care NeedsObtain Necessary ConsultsAssign Primary Responsibility for Care and

Communicate the Identity of the Primary Physician and the Physician's Contact Information to Family and Health Care Team

2. PRESERVE: Preserve the EvidenceSequester Machinery (Pumps, Anesthesia

Machines) and Preserve SettingsSequester Equipment (Syringes, IV Tubing,

Medication Vials)Inform Hospital Risk ManagerInform Maintenance Department or SupplierAcquire Back-up Equipment

3. DOCUMENT: Document in the Medical RecordWhat to Include: "Known Facts" About Unanticipated

Outcome Care Given in Response Disclosure Discussion and Names of

Witnesses (see Step 5 ). Treatment and Follow-up Plans

3. DOCUMENT: Document in the Medical RecordWhat Not to Include: Subjective Feelings or Beliefs Speculation or Blame References to Incident Report Forms or

Event Analysis “Confidential” Information 

3. DOCUMENT: Document in the Medical Record Begin the Event Analysis by Completing

An Incident Report Communicate “Known Facts”Avoid Speculation or Blame “Confidential” Document Do Not Place in Medical Record or Discuss in

Medical Record Do Not Photocopy 

4. REPORT: Complete Mandatory Reports If Required

Inform Hospital Risk Management.Inform Public Health Department and/or

Other Governmental Agencies

5. DISCLOSE 

The Initial Disclosure DiscussionWhy, Who, When, Where?

DISCLOSEWhy Disclose Unanticipated Outcomes?Patient Has Right to Know Condition and Make Health

Care DecisionsImproves Doctor/Patient RelationshipRebuilds TrustQuality of CareProfessional Code of EthicsStandard on Patient Safety and Error Reduction8May Be Required by Hospital Staff By-Laws, Medical

Group Policies andProcedures, Health Plans, and Health Care

Organizations

DISCLOSE Who Will Inform Patient? Health Care Provider(s) Involved in the

Unanticipated OutcomeProvider(s) With Responsibility for Ongoing Care Person(s) With Ability to Answer Questions  Persons Involved in Disclosure Discussion May

Need Assistance inPreparing, Coordinating or Conducting

Discussion, Depending Upon: Communication Skills Rapport with Patient and Family Language Barriers

DISCLOSE When to Inform Patient and Family? As soon as Practicable After Immediate

Health Care Needs Addressed Consider Patient’s Physical and Emotional

Readiness Patient’s Permission Needed to Discuss Care

with Family  Where to Hold Discussion Consider Privacy and Health Needs

DISCLOSEHow To Disclose Unanticipated OutcomesExpress EmpathyConvey Compassion for Patient’s and Family’s Pain and

Suffering “I’m sorry that you…” of “I am sorry for your…”Focus on Patient’s and Family’s NeedsAvoid “I am sorry that I…”Avoid Speculation and BlameSolicit and Respond to Patient’s/Family’s Feelings and

Questions Respond to Patient’s ComplaintsPlan for Follow-up Care and More Discussions and

Communicate the Plan

6. ANALYZE:Analyze Unanticipated Outcome to

Prevent Recurrence and/or Improve Outcome

7. HEAL:

Heal the Health Care Team Acknowledge Effect on Health Care Team Members

Unanticipated Outcomes Disturbing to All Involved

Identify Resources to Help in HealingAllow Time for Resolution of Feeling

Improving Patient SafetyResearch funded by AHRQ and others has

been important in identifying the extent and causes of errors. Now, additional research is needed to develop and test better ways to prevent errors, often by reducing the reliance on human memory. Some areas of past research that have shown promise in helping to reduce errors include computerized ADE monitoring, computer-generated reminders for followup testing, and standardized protocols

Thank you

presented by : Ibraheem al jazei

REFRENCESWWW.NPSF.ORGWWW.RIGHTDIAGNOSIS.COMWWW.WIKIPEDIA.COMWWW.AHRQ.GOV