Medical error happens at an alarming rate
Adverse outcome data reported by the Institute of Medicine (IOM) in 1999 revealed that healthcare provider error resulted in 44,000 to 98,000 patient deaths per year1. This was higher than the number of deaths from traffic accidents, Healthcare provider error resulted in 44,000 to 98,000 patient deaths per year. breast cancer and HIV infection. These numbers place patient death from clinical error as the fourth to ninth leading cause of death in the United States1. According to the report, the overall social cost of clinical error approached $38 billion annually. Approximately half of this ($17 billion) was associated with preventable errors.
In 2000, in the United Kingdom, the National Health Service (NHS) reported that adverse events occurred in association with 10% of all hospital admissions. This resulted in 850,000 reported events at a cost of 2 billion pounds to the NHS annually2.
70,000 of these events were potentially preventable. In 2004, the Canadian Adverse Events Study3 reported a 7.5% incidence of adverse events for all admissions to Canadian hospitals. This study included data from a random sample of charts for non-obstetric, non-psychiatric adult patients in acute care hospitals in five provinces (British Columbia, Alberta, Ontario, Quebec and Nova Scotia) for the fiscal year 2000. It was estimated that of the nearly 2.5 million admissions to hospitals, 185,000 were associated with an adverse event. Almost 70,000 of these events were potentially preventable. The authors also indicated that there were 9,250 to 23,750 preventable deaths from adverse events during this period.
Also in 2004, a report by HealthGrades (Colorado) suggested that the number of deaths due to medical error had been underreported in the IOM study. Data from their review estimated that approximately 195 000 deaths per year were due to preventable hospital errors4.
In 2011, a study on the ‘Global Trigger tool’ suggested that the assessments to date may be underestimating the issue by a factor of 105.
In 2013, John James wrote in the Journal of Patient Safety the following conclusion following his study: “Given limitations in the search capability of the Global Trigger Tool and the incompleteness of medical records on which the Tool depends, the true number of premature deaths associated with preventable harm to patients was estimated at more than 400,000 per year. Serious harm seems to be 10- to 20-fold more common than lethal harm."
His conclusion is particularly poignant:
“In a sense, it does not matter whether the deaths of 100,000, 200,000 or 400,000 Americans each year are associated with PAEs (Preventable Adverse Events) in hospitals. Any of the estimates demands assertive action on the part of providers, legislators, and people who will one day become patients. Yet, the action and progress on patient safety is frustratingly slow; however, one must hope that the present, evidence-based estimate of 400,000+ deaths per year will foster an outcry for overdue changes and increased vigilance in medical care to address the problem of harm to patients who come to a hospital seeking only to be healed.”6.
Clinical error in obstetrics
Obstetrics is a rather unique area of healthcare. Childbirth is a normal physiological process – it isn’t an illness! – and most of the time everything goes well.
When things don’t go well, and the mother or baby experiences harm – whether due to error or not, the impact can be devastating – death or severe morbidity – in a scenario where expectations are for a normal, happy life event.
These events have a profound impact on:
- Families - obviously
- But also care providers
- Personal level
- Professional level
- Healthcare organizations
- Liability - cost
Because of the profound impact emotionally, and because of the long-term financial burden that ensues from harm suffered by a child at birth, there is a high risk of legal action following a harm event in obstetrics.
Why do errors happen?
So we know that patient errors occur and the impact is significant. But why do errors happen in a group of dedicated, motivated and educated professionals?
There are several reasons. The first is because we are human. And the second is that we are humans who work within flawed systems. This program will focus on a systems approach to building Patient Safety.
The basic premise in the systems approach is that humans are fallible and errors must be expected, even in the best organizations. Errors are seen as consequences rather than causes. The important issue is 'not who blundered, but how and why the defenses failed.
Human factors and cognition processes can lead to errors
The human brain has limited short term memory capacity and room to process information; therefore has an unconscious system of moving information into long term memory, stored in patterns. This frees up cognitive space to use critical thinking skills to deal with new information. Sometimes referred as system 1 – learning is so ingrained that it is almost automatic – we don’t need to think, we just react to patterns. Humans have the ability to organize complex tasks into automatic functions which frees the mind up for other tasks. When 'X' is present we automatically do 'Y' based on training, experience, etc. The brain sees what it expects to see. This sets us up for slips and lapses when we aren't focused.
System 2 refers to the critical thinking side – it takes longer to make sense of a situation; we often see this with beginning practitioners who take longer to come to a decision because they have to think through things – they don’t have enough experience to have established patterns (operate in system 1).
When we encounter a new situation, we generalize based on past experience. This provides us with a basis to develop an approach. However with that comes bias and a tendency to oversimplify or be overconfident increasing the potential for errors.
The final element of human factors leading to errors is “Routine Violations”, which can also be termed 'normalization of deviance'. This is where small changes or deviations from accepted methodology become the norm for the individual or the unit. When this occurs without problem, additional deviations are accepted more easily. This leads to a situation in which violations are tolerated because ‘we have always done it this way and nothing ever bad happens’ so it continues.
Systems can lead to errors
A system is a set of interdependent elements interacting to achieve a common aim. The elements may be both human and non-human (equipment, technologies, etc.)7. No accident is ever caused by just one thing – it is always a series of things and involves an organization and how it operates – it never comes down to just one individual.
Hospitals function through the close interaction of multiple systems that are often individually highly specialized and at the same time very interdependent. This defines a 'complex adaptive system'. Systems that are very complex and tightly coupled with or dependent on each other are more prone to accidents and have to be made more reliable. Failures or changes in one part of one system can result in unexpected failures in other, indirectly associated systems. The high degree of specialization in individual systems within hospitals and the lack of direct inter-system transfer of information, small failures or changes in one system can result in major accidents in others.
1. Kohn LT, Corrigan JM, Donaldson MS. To err is human: building a safer health system. Washington: National Academy Press; 2000.
2. Department of Health. An organisation with a memory: report of an expert group on learning from adverse events in the NHS. London: The Stationery Office; 2000. Available: http://www.dh.gov.uk/assetRoot/04/06/50/86/04065086.pdf.
3. Baker GR, Norton PG, Flintoft V, Blais R, Brown A, Cox J, et al. The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada. CMAJ 2004;170(11):1678-86.
4. HealthGrades in the news. Golden (CO): Health Grades, Inc.; 2006. Available: http://www.healthgrades.com/media/DMS/pdf/HealthGradesInTheNews.pdf (accessed 2006 Oct).
5. Classen DC, Resar R, Griffin F et al. 'Global trigger tool' shows that adverse events in hospitals may be ten times greater than previously measured. Health Aff (Millwood) 2011;30(4):581-589.
6. James JT. A new, evidence-based estimate of patient harms associated with hospital care. J Patient Saf 2013;9(3):122-128.
7. National Health Service. Report of an expert group on learning from adverse events in the NHS chaired by the chief medical officer. An organization with a memory; 2000.