University of Sulaimani Name:‫اللۆ ئاکۆ صديق‬

College of Medicine Stage:

First stage ( S1)
Subject: Critical Thinking
Critical Thinking

2019-2020
Code :

Student Code :

Assignment Marks in No. Marks Written Signature

Introduction

Details

Conclusion

References

Total mark

Title: Medical errors

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Introduction: Patient Safety is a health care discipline that emerged with the developing
complication in health care systems and the resulting arise of patient harm in health care facilities .
It seeks to prevent and reduce risks, errors and suffering that occur to patients during provision of
health care, a basis of the discipline is ongoing improvement based on learning from errors and
adverse events (WHO). Patient safety is a subject that covers all medical specialties and affects
every health-care professional. To confirm successful implementation of patient safety strategies
such as clear policies, skilled health care professionals, effective involvement of patients in their
care, leadership capacity and data to drive safety improvements are all needed. Errors or mistakes
happened by health professionals which may result in harm to the patient, they include errors in the
management of drugs and other medications (Medication Errors), errors related to diagnosis
(Diagnostic Errors), errors in doing surgical procedures, in the use of other types of therapy, in the
use of equipment, and in the interpretation of laboratory findings. Medical errors are discriminated
from Malpractice in that the former are regarded as honest mistakes or accidents while the latter is
the result of reprehensible ignorance, negligence or criminal intent.

Medical error is a preventable adverse effect of medical care, whether or not it is evident or harmful
to the patient, Or a medical error, as defined by the Institute of Medicine (IOM), Is “the failure to
complete a planned action as intended or the use of a wrong plan to achieve an aim.” a medical
error must be distinguished from an adverse event, which is “an injury caused by medical
management rather than by the underlying disease or condition of the patient.” An adverse event
results in harm to the patient. Not all medical errors lead to adverse events. In fact, most do not. The
attention to medical errors and adverse events as well as the resultant literature has extended
exponentially over the past decade

Details: Medical errors are critical matters in the practice of medicine medical practitioners
should become familiar with causes of medical errors and mechanisms of preventing them. Medical
errors have legal and ethical implications. The Institute of Medicine (IOM, now known as National
Academy of Medicine) publicized the monograph “To Err is Human” in 1999, alerting the medical
community that medical errors were frequent in medical practice. According to the IOM report, “at
least 44,000 people and perhaps as many as 98,000 people die in hospitals each year as a result of
medical errors that could have been prevented.”(1999). One of the 1999 IOM report’s main
conclusions is that the majority of medical errors do not result from specific recklessness or the
actions of a particular group. More commonly, errors are originated by failure systems, processes,
and conditions that lead people to lead to mistakes or fail to prevent them. For example increased
cost cutting has certainly contributed to compromised patient safety. For example, these days,
physicians are often being obligated to see two or even three times as many patients in a day.
Biased provider judgment, fragmented communication including illegible record keeping, sleep
deprivation, and lack of continuing education and training are some other common error sources,

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and also stocking patient-care units in hospitals with certain full-strength drugs, even though they
are toxic unless diluted, has resulted in deadly mistakes.

And by now medical error has been presumably identified as among America’s leading causes of
death, the most recent study in 2013 indicated the numbers range from 200,000 to 440,000 deaths
per year. The latter number would make it the third leading cause of death after heart disease and
cancer, medical errors are often considered as the human error factor in healthcare, this is a highly
complicated subject related to many factors such as incompetency, lack of education or experience,
language barriers, illegible handwriting, gross negligence, inaccurate documentation, and fatigue to
name a few. There are also many different types of errors ranging from medication errors,
misdiagnosis, surgical mishaps, under and over treatment . Medical errors are also associated with
extremes of age, urgency, new procedures and the severity of the medical condition being treated.
The nine most common medical errors in the United States in 2014, by occurrence are: adverse drug
events, central line-associated bloodstream infection (CLABSI), catheter-associated urinary tract
infection (CAUTI), injury from falls and immobility, obstetrical adverse events, pressure ulcers,
surgical site infections (SSI), and ventilator-associated pneumonia (VAP), venous thrombosis
(blood clots), medical errors can occur anywhere in the health care system: In hospitals, surgery
centers, clinics, doctors offices, pharmacies, nursing homes, and patients homes. Errors can happen
during even the most routine tasks, such as when a hospital patient on a salt free diet is given a high
salt meal

Here is some common root causes of medical errors which include:

Communication Problems

Communication failure is one the foremost frequent factor for medical flaws. Whether verbal or
written, these issues can arise in a medical practice or a healthcare system and can happen between
a physician, nurse, healthcare team member, or patient. Poor communication many times results in
medical errors.

Issues related to diagnosis (Misdiagnosis, Delayed diagnosis)

Diagnostic mistakes are another most frequent medical mistake as well as the most serious, These
consist of failure to diagnose, delayed diagnosis or an incorrect diagnosis. Misdiagnosis is a
condition in which a medical professional definitively offers a prognosis based on the symptoms
they know and tests results, but the prognosis ends up being wrong and the condition is actually
something else. Misdiagnosis can also be a condition in which there is a missed diagnosis. This is
when the medical professional notifies the patient that s/he is healthy but there actually is something
wrong with their health status. A delayed diagnosis can be as detrimental as a misdiagnosis. A delay
in diagnosis can prevent the patient from getting certain treatment in a timely manner. Misdiagnosis
could involve one or more of the following: failure to establish a differential diagnosis, failure to
address abnormal findings, failure to order diagnostic tests, failure to consider available clinical
information. Other issues adversely influencing the diagnostic process were a failure to obtain a
consult and a premature discharge from the ED.

Medication error

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It’s another most common fault that takes place in the path of medical treatment is an error in
prescribing drugs. Prescribing the wrong dose or failing to account for drug interactions can have
damaging effects for the patient. Prescribers and caregivers must carefully review a patient’s
medical history to look for allergies and potentially harmful drug combinations before
administering medicine. If they fail to do so, or if information is left off of a patient’s chart, the
consequences can be very serious.

Inadequate Information Flow

Data flow is critical in any healthcare background, specially within different service regions. poor
information flow happens when necessary information does not follow the patient when they are
transferred to another facility or discharged from one component or organization to another.
Inadequate information flow can arise the following consequences:

• Lack of proper communication of test results.

• The lack of crucial data when needed to influence prescribing decisions.
• Poor coordination of medication orders for transfer of care

Human Problems

Human-being related problems occur when quality of care, processes, policies or procedures are not
followed decently or efficiently. In Some cases involve poor registration and labeling of specimens.
Knowledge based errors also happens when individuals do not have adequate knowledge to provide
the care that is needed at the time it is required.

Patient-Related Issues

These may include improper patient identification, insufficient patient assessment, failure to acquire
consent, and inadequate education.

Organizational Transfer of Knowledge

These issues can cover inadequate in training and inconsistent or insufficiency education for those
providing care. Transfer of knowledge is critical in most areas specifically where new employees or
temporary help is used

Staffing Patterns and Workflow

Staffing patterns and work flow can result errors when physicians, nurses, and other health care
workers are too busy because of insufficient staffing or inadequate supervision. incomplete staffing
singly doesn't lead to medical errors but can put healthcare workers in conditions where they are
more about to make a mistakes.

Technical Failures

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Mechanical failures can involve issues or failures with medical devices, implants, grafts, or pieces
of equipment.

Medical errors are everyone’s business and everyone’s responsibility. Either you are a healthcare
professional, a family caregiver, or a patient, the more you have information, the better you can
protect yourself and others, how much you need to know differ with your situation. Nursing
professionals need a broader range of knowledge about medication errors, but every occupational
or physical therapist will be better able to observe and protect their patients if they own an
appropriate understanding of the effects and symptoms of medication problems, the same is
essentially correct across all categories of medical errors, an individual may not require to know as
much detail as the healthcare professional, but the bottom line is that we each must be advocates for
our own healthcare. We need to be prepared to recognize possible problems and ask questions of
our healthcare providers and to know when to take action, our culture has not always been one that
encourage questioning of authority figures but, as with all things human, mistakes can happen in
healthcare and those mistakes can have life changing or life ending consequences.

Even though medical errors are inevitable but they are preventable, blaming an individual does not
alter these factors and the same error is likely to recur, preventing errors and improving safety for
patients needs a systems approach in order to modify the conditions that contribute to errors. People
who are working in healthcare are among the most educated and dedicated workforce in any
industry. The problem is not bad people, the problem is that the system have to be made safer.
Along with the best endeavors of health care practitioners, virtually all doctors have made mistakes
but they often don’t tell families or patients about them, In clinical practice human errors are
common and inevitable but they are generally under-reported, as a outcome of this under-reporting
very little is known about the causes and consequences of medical errors. Furthermore facing to a
medical error is never easy and hence it is not disclosed. It is often hard to recognize one’s fault but
it is necessary to face the situation and try to discover from it so that future errors can be prevented.
Identifying the risk factors for medical errors is pivotal first step towards its prevention and is
important goal of quality care assurance.

There is an agreement that disclosure of medical mistakes is ethically and legally appropriate but
such revelation are made hard by medical traditions of concern about medical malpractice lawsuits
and by physicians own emotional reactions, Because the physician may have compelling reasons
both to keep the information confidential and to disclose it to the patient or family these situations
can be conceptualized as privacy dilemmas. Revealing medical mistakes is difficult because of a
long history of feeling reticent about revealing such information and because of physicians’ strong
emotional reaction to mistakes, both of which lie in tension with the inviolable ethical obligation to
be honest with patients. On one hand, there often is a culture among physicians that may lead to
concealment of disclosure; on the other hand they are ethically expected to disclose mistakes to
patients and their families. These contradictory expectations can lead to a privacy dilemma for
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physicians who must determine whether, when, and how to reveal. Anxiety about disclosure of
mistakes may be worsen by fears that the information surrounding mistakes will be made to public
that the patient may act by requesting cost reimbursement, or that disclosure will end in legal
consequences. Currently evidence indicates that physicians are not adequately equipped to manage
such disclosures successfully and there may be some level of defensiveness that interferes with
decent disclosure.

One difference of opinion for not revealing all medical errors revolves around the belief that it
would erode the public's trust in medical institutions In disclosing all medical errors, patients may
become disappointed with physicians in general and lose faith in the medical line. However,
research findings indicate that patients actually have increased trust in the medical system when
they feel that physicians are not withholding information from them.

Surveys have helped to define the components of disclosure that matter most to patients. These
include:

• revealing of all harmful mistakes

• An clarification as to why the error happened
• How the error's effects will be lessen
• Steps the physician (and organization) will take to prevent recurrences

Conclusion
Patients believe that they’re in good hands and completely trust in the decisions and skill of their
doctors and nurses. However, sometimes even they can make mistakes. Most errors result from
problems made by today's complex health care system but errors also occur due to individual
healthcare practitioners mistake. Adverse events and medical errors affecting patient care are
recognized universally as major issues in medicine. The failure of health care professionals and
health institutes to address this problem has threatened to diminish public confidence in the health
care system as a whole. Less focus has been directed at the ethical issues raised by negative
outcomes of care, specifically the issue of disclosure. Medical records are often imprecise and
providers might be reluctant to disclose mistakes, some doctors could be reluctant to admit fault.
Self-perceived medical errors are common among doctors and are associated with subsequent
personal distress, Minimization or outright refutation that errors exist in the first place will without
a doubt ensure the perpetuation of this problem. Attempts to prevent negative outcomes of care
must be supplemented by policies of increased honesty and openness with patients and their
families about adverse incidents. Disclosure of errors to patients is required by patients and
recommended by ethicists and professional organizations, it is important to learn from faults rather
than oppose them. Physicians have traditionally shied away from discussing errors with patients, in
part due to fear of precipitating a malpractice lawsuit, but also due to embarrassment and discomfort
with the disclosure process. Disclosure should be made easier for healthcare practitioners so
clinicians can learn from faults and develop patient care but little is known about how patients and
physicians think medical errors should be discussed, the error disclosure process must be handled
thoughtfully and sensitively to avoid alienating patients and families

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References:
https://pubmed.ncbi.nlm.nih.gov/11151522/

https://pubmed.ncbi.nlm.nih.gov/1987460/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3056201/

https://www.medlink.com/article/medical_errors

https://www.scribeamerica.com/blog-post/medical-errors-causes-solutions/

https://archive.ahrq.gov/research/findings/final-reports/pscongrpt/psini2.html

https://munley.com/the-most-common-medical-errors/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4928391/

https://www.atrainceu.com/content/3-types-medical-errors

https://jamanetwork.com/journals/jamasurgery/fullarticle/1107400

https://www.contemporarypediatrics.com/view/prevent-medical-errors-your-practice

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3662285/

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