Medical Errors: Faulty Health Care System

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Medical or health professionals are considered to be the most respected and most valued persons. These professionals are source of hope for people suffering from different diseases. This puts additional responsibility on the doctors and health professionals and they are required to be more careful and cautious while performing their operations and duties.

Despite of all special care and caution on part of the health professionals, there are increasing number of medical errors. Medical errors are defined as the mistakes or faults done by the health or medical professionals resulting in harmful and dangerous implications for the patients. These include errors in the process of diagnosis known as diagnostic errors, mistakes in the management of drugs and prescribing medicines known as medication errors, faults or mistakes in the while performing procedures of the surgery, while using any other therapy, while using any equipment, and while interpreting the reports and findings of the reports. Some of the examples of medical errors are (Rogers):

Preventive errors.

Medication errors.

Surgical errors.

Preoperative errors.

Operative errors.

Postoperative errors.

Diagnostic errors.

System failure

Medical errors can result in serious and dangerous implications not only for patients but also for the professional and the medical institution. Apart from this medical errors can be costly, can result in stressful situations, can consume extra time, and can be disturbing for the person.

There can be different reasons behind medical errors. These errors are mostly related with the inexperienced doctors and medical staff, new and inefficient methods, cases requiring intensive care, improper communication and documentation, poor ratio of nurse to patient, and medications with similar names. Apart from these sometime the actions of the patients also result in serious medical errors. Imperfect and flawed system along with improperly designed process are responsible for large numbers of medical errors (Institute of Medicine).

The consequences of the medical errors are different depending on the severity of the situation and on the behavior of the health professionals. It is the ethical duty and responsibility of the health professionals to accept their mistake and communicate about it.

Medical errors are just not the problem of one or two individuals it is linked with the whole health care system and should be dealt in keeping this into consideration.

THESIS STATEMENT:

"Mostly medical errors occur either because of improper communication or because of inappropriate planning and error in implementing the plan."

Medical errors can be done anywhere in the complete process of providing medical care to the patients. Most of the medical errors or mistakes happen because of the fault in the system of the institution or because the health professionals and doctors are not able to implement the process accurately. Along with this there should be a proper reporting system for the medical errors so that those mistakes and errors are not repeated in future.

HISTORY:

The issue of medical errors is not new and is existing from the very beginning. But this issue or problem has been neglected and have not given the deserved consideration and attention. In 1990 a special body emerged for the purpose of describing the issue of medical errors and its implications on the quality of the health care solutions. Medical errors were classified as one of the four major difficulties or challenges faced by the health care professionals in the process of improving the quality of the health care services and solutions (Institute of Medicine).

Medical errors have serious implications and consequence. These errors lead to the death of around 180,000 people every year, more than the deaths because of cancer, accidents, and AIDS. This results in making medical errors the fifth largest reason behind the death. Within all medical errors, around 7,000 deaths per year are because of the medication errors (Institute of Medicine).

There has been an increasing public concern about the medical errors. People are now becoming more aware of the issue and are demanding for more care and safety. According to a research by the national patient safety foundation around 42% of the people had been influenced by medical error. At the same time a research conducted by American Society of Health system Pharmacists revealed that around 61% of the people are worried about getting the inappropriate medicine, 58% of the people are worried about the receiving two or more such medicines which have negative combine effect, and around 56% of the people are worried about the negative consequences and complications of a medical treatment or procedure.

After analyzing different adverse or sentinel events from 1995 to 2010, the Joint Commission presented...

These six categories were (Rogers):
1. Surgery on wrong site (13.4%)

2. Suicide committed by the patient (11.9%)

3. Complications and issues during operation or after operation (10.8%)

4. Treatment delays (8.6%)

5. Medication errors (8.1%)

6. Patient falls (6.4%)

There is high cost associated with the medical errors not only in terms of financials but also in moral terms. Medical errors result in reducing the trust of people over the health institutions and health care system and diminishing the satisfaction of the patients and health professionals. According to the report of the Institute of Medicine, around $37.6 billion per year is the cost incurred because of the medical errors. Out of this total cost, the cost related with the preventable errors is estimated to be within the range of $17 million to $29 million every year (Institute of Medicine).

CASE STUDY:

Case Study 1:

17-Year-old Jesica Santillan Died after receiving wrong heart and lungs:

At Duke University Medical Centre, a 17-year-old girl died because of medical error. She died because she received wrong heart and lungs. Santillan was a Mexican immigrant who had serious heart condition that's why she came to America for medical treatment. She approached Duke University Hospital in Durham N.C. And doctors suggested that her condition could improve after the heart-lungs transplantation but doctors at hospital failed to check compatibility and began the surgery.

Doctors transplanted heart and lungs of a patient whose blood group didn't matched with the blood group of Jesica Santillan. Jesica had blood group of type O but she received the type A- donor's organs. So after surgery she endured brain damage and she died.

The main reason of this incident was that Duke University Hospital didn't have safeguards to ensure a compatible transplant (Archibold).

Case Study 2:

Another case which can be quoted here is about the medication error.

This case study is about Jasmine Gant, a girl who died because of medical error by St. Mary's Hospital. She was at hospital (St. Mary's Hospital) preparing to give birth to her son. The state department of health and family services conducted research on her death and report showed that one of the nurses at hospital gave her wrong medicine. That nurse was supposed to give penicillin intravenously but she gave epidural painkiller to Jasmine Gant. So because of reaction that wrong painkiller Gant had an attack and she died.

The main reason of that incident was that the nurse didn't follow the protocol to make sure that the patient received correct medicine. Report also concluded that St. Mary's Hospital didn't have care plans which list the standard operating procedures of provide care to different patients. Staff of St. Mary's Hospital was also unaware of drug-delivery policies. The state of department of health and family services investigation found that hospital had deficiency in three main areas (Channel3000).

1. Hospital failed to establish care plans for patients.

2. Hospital didn't have procedures for safe handling and administration of medicines.

3. Hospital didn't communicate drug delivery policies with its nursing staff.

CURRENT TRENDS:

According to the Institute of Medicine most of the medical errors are related to the issues and problems with the system are not only because of the negligence or ignorance of the health professionals. Current trends suggest that frequency of medical errors can be reduced by focusing on the performance of the complete system of provide health services and health solutions and striving to improve this system. The solution is not to blame the health professionals, they are human and can make errors, but different researches and studies have proven that the improvement in systems have resulted in reducing the rates or frequency of the errors and ultimately contributes towards improving the quality of the overall health care (Institute of Medicine).

The major issue or problem is the decentralized and inappropriate system or no system at all. Because of ineffective system and improper communication modes, the health providers do not have complete access to information and this results in different errors and mistakes.

The main focus at the moment is to build such a health system which is effective and efficient and reduce the chances of different kinds of errors or mistakes. As it is being perceived that most of the medical errors are result of inappropriate systems, communication process, and other conditions and circumstances which force the health care providers to make errors (Rogers).

The solution suggested by the Institute of Medicine in this regard is that there should be a strong and safe health system which makes it difficult for the health professionals to make any error or mistake. Along…