The Best Practices: Avoiding and Reporting Medical Errors

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If you’ve worked in healthcare long enough, there’s a good chance you’ve had some experience with medical errors. Making a mistake feels bad enough, but when it affects the health or wellbeing of someone in your care it can weigh on your mind and conscience well beyond the end of your shift. The simple fact is, the healthcare industry is run by human beings. It’s only as error free as the systems it puts in place and the people who administer the protocols, and that means mistakes are inevitable. Unfortunately, medical errors can also have dire consequences, and they represent a costly public health concern that is a leading cause of death in the U.S. today. The best way to combat the epidemic is to bring problems to light and institute changes through better systems and training. That means establishing a culture of reporting medical errors, a clear chain of ownership, and participating in continuing education to ensure staff are informed and empowered to make a difference in the future.

The Cost of Errors

Approximately 400,000 hospitalized patients in the United States experience some form of preventable harm each year, with 100,000 incidents resulting in death. As frightening as that sounds, those numbers don’t even include patients managed outside of the acute care setting. The overall figure may be much higher! Medical errors can also impact patients in a variety of different ways. Incorrect or missed intervention can result in additional or prolonged treatment, extended hospital stays, rehabilitation, and permanent disability. In terms of dollars, medical errors represent a loss of about $20 billion per year, and traverse multiple aspects of care that include surgical procedures, diagnostics, medications, infections, and health technology.Finally, there is the toll medical errors take on the healthcare professionals themselves. They may experience feelings of guilt, shame, and anxiety that can translate into more tangible negative outcomes like burnout, lack of concentration, depression, and post-traumatic stress disorder. The simple fact is, a lack of support for the person who made a mistake may actually result in more problems down the road, and can negatively impact the culture of reporting medical errors in the institution as a whole.

How Mistakes Are Made

Medical errors can be divided into two general categories: errors of commission, and errors of omission. Each has their own root causes and solutions, and both can be extremely harmful if left unchecked.

Commission

Errors of commission occur when a healthcare worker does something incorrect. They’re not typically intentional, but they are nonetheless harmful in some way. Giving a patient the wrong medication or in the wrong dosage are common errors of commission that can happen quickly and easily if proper protocols are not in place and followed correctly. They can also happen in administrative settings, like miscoding a patient’s file or switching an appointment date. Errors of commission can be extremely traumatic for both healthcare professionals and patients alike, and depending on the cause and outcome they may result in fines, loss of licenses, malpractice suits, and even criminal charges.

Omission

Omission errors are the result of an action that was not taken. Forgetting to order blood work or overlooking an obvious symptom of disease are examples of errors that can hurt a patient by not maintaining standards of care. Acts of omission are generally easier to correct than acts of commission because they tend to  result from a lack of training or protocols, whereas acts of commission often happen despite appropriate guardrails being in place. Investigation and analysis of omission errors can lead to better outcomes through additional education and improvements to internal systems.

Error Reporting

A well-rounded conversation on medical errors must include attention to reporting. The simple fact is, an error that is not reported can’t be corrected, and may cause more collateral damage down the line.  Naturally, reporting an error made by oneself or a colleague can cause fear and anxiety, and it’s critical that all healthcare employees work to eliminate barriers to reporting. Common examples include:

• Fear of getting in trouble
• Fear of getting a friend or colleague in trouble
• Unsupportive work culture
• Lack of formal reporting system
• Lack of understanding of the importance of reporting
• Time and energy

These concerns are what gave birth to concepts like creating high-reliability and just cultures. In the past, the response to a medical error was to blame and shame the person involved, which reinforced an extraordinary reluctance to report in the first place. Developing a just culture that is conducive to reporting medical errors begins with acknowledging that errors are often systemic rather than individual. In the end, reporting medical errors is about reducing future harm, and fostering an open,  supportive environment translates to better outcomes for everyone.

Encouraging Better Reporting

There are several approaches that can be implemented to overcome cultural and procedural barriers to reporting by creating a more supportive and transparent culture, such as:

• Improving communication
• Leveraging technology in processes like medication administration and patient identification
• Using computer-assisted order entry programs
• Standardized evidence-based infection control policies
• Limiting shift length to prevent fatigue

These are just a few examples of great ways to reinforce safe practice, but to be successful, healthcare workers need to know the “why” behind the “what”. Continuing education in best clinical practices through courses like those offered by Premiere develops a strong foundation of understanding that leads to better action and improved outcomes in healthcare.

Help Support Best Practices in Avoiding and Reporting Medical Errors

While improving safety measures is critical to mitigating medical errors, healthcare professionals need the knowledge and understanding of their impact to complement safe processes and improve outcomes. Medical and Medication Error Prevention by Amy Adkins-Dwivedi MS, APRN, has been developed by Premiere to instruct healthcare workers on how to define, characterize, and implement a multidimensional approach to reducing and reporting medical errors. With a little investment in continuing education to stay informed, vigilant, and empowered, you can be a part of creating better healthcare outcomes for everyone.