Medical Errors Are Preventable Adverse

Medical errors are preventable adverse effects of care, legally noted whether or not it is intended to be harmful to the patient or simply accidental. Examples might include an inaccurate or incomplete diagnosis, an inappropriate treatment, mistake in prescribed medicine, or any other event that leads to a negative consequence. While medical errors are often subjective, and subject to debate within both the medical and legal community; data is based on administrative records, not clinical, as well as insurance data. Often, too, it is difficult to determine causality, since the human body is simply so complex that no medical professional can ensure they can diagnose or operate with 100% accuracy (Hayward and Hofer, 2001). In the United States alone, however, medical errors are estimated to be between 50-100,000 unnecessary deaths in hospital or clinical settings; and over 1 million excess or unnecessary injuries per year. Between the decade 1996 and 2006 a conservative average from both the Institute of medicine and HealthGrades Reports showed somewhere between 500,000 and 1.2 million deaths caused by medical error. The range is indicative of the lack of appropriate information to accurately define error and attribute an actual cause to an actual effect (Epidemiology of Medical Error, 2000).

Human Error and the Practice of Medicine -- in any endeavor in which humans are involved, there is a margin of error present; from engineering to mechanics; from baseball to education. And yet, for some reason, society in general does not believe it is possible to have errors in the medical profession. There are several things to remember about modern medicine, however. First, the human body is an incredibly complex organism that does not always operate the same from individual to individual. Each person brings another set of complex equations (age, general health, diet, genetics), and the system becomes so complex it is almost bordering on chaos theory. Some systems are more prone to accidents than others because of the way various components are linked together. Health services is one of them -- it must combine the human element with technology, timing, the patient's needs, a certain amount of unknowns, and, in most cases, an unfamiliarity of all the details with which to work (Rathert, Fleigh-Palmer and Palmer, 2006).

The complex nature of medical care juxtaposed with the complex nature of human performance, especially in urgent and trauma care settings can, at times, cause a number of errors. Based on a 2000 report from the Institute of medicine entitled "To Err is Human" lists a number of common errors, but also asserts that the issue is not so much that there are a lot of incompetent people in health care; it is more that good people are working in a system that is fraught with difficulties and situations that often engender error (Kohn, Corrigan and Donaldson, 2000). Overall, the most common medical errors in the United States are:

Poor communication; unclear lines of authority, poor handwriting, language issues.

Disconnected reporting systems within a medical organization; fragmented systems that assume another group is handling and issue

Over-reliance on automation or technology to prevent errors

Inadequate systems to share information between department; lack of synergistic control

Cost-cutting measures by hospitals in response to HMO and insurance issues

Environmental and/or design factors -- areas poorly suited for specific kinds of patience

Infrastructure failures; including, equipment problems in manufacture or utilization of untrained personnel

Extreme fatigue resulting in overscheduling staff

Depression, burnout, and other human issues common to stressful situations

Staffing issues as patient to nurse ratio increases (Physicians Want to Learn from Medical Mistakes, 2008; Improving America's Hosptials, 2010).

That being said, within the medical profession a number of safeguards and checks are already in place that minimize errors. One must look at the statistics of the events, though. For instance, we know that statistically, it is safer to travel by airplane than by car. However, publicity surrounding airline accidents is greater, so the perception becomes that it can be dangerous to fly. Similarly, if one takes into account the number of people treated per day all over the United States, the number of operations that occur, and the number of prescriptions that are filled, the error ratio is quite small -- it just becomes perceptually larger due to the severity and impact of the events. One of the greatest contributors to accidents in any industry is indeed human error. But saying that an accident is due to human error is not identical to assigning blame because somewhere along the way the system has failures that contribute to human error -- even if slight (Johnson, 2007).

Conclusions - by the very nature of culture and humanity, humans tend to be group animals -- they thrive in groups, coalesce into groups, indeed, the very process of moving from hunter-gatherer to cities was part of a group behavior. Group norms are internal rulings that are followed by individuals so that the synergistic effect of the group will be more efficient. These values usually focus on the way members of that group look and behavior towards themselves, and the hierarchical structure they tend to set up to "police" their efforts. Norms help groups solve problems, define and address new situations, make better decisions, and even process their daily work. Groups, in this case members of the medical community, join these groups in order to reflect specific notions and values associated with the overall group. Normative behavior in the medical field is covered by a willingness to help, to "do no harm," and to provide the best possible solutions to the set of circumstances given. There is a clear difference in issues in which a patient expires due to inadequate equipment, prior condition, or even no apparent clinical reason if all procedures were followed to the best of the caregiver's ability -- and a case in which because of substance abuse or other incompetencies the wrong medicine is ordered or something surgical is mishandled. Thus, all errors are not malpractice; and all errors are not purposeful or caused by a lack of attention or ineptitude (Kohn, Corrigan and Donaldson, 2000)

Traditionally, in the medical field, errors are attributed to mistakes made by individuals who may be punished for those mistakes. Typically, the approach is to correct the error(s), create a new set of rules and additional checking steps within the system, hopefully preventing area. However, a newer model for improvement, based on the Total Quality Management Programs in business, takes a different approach. In this model, the focus is on identification of the underlying system defects that allow the opportunity for an error to even occur. Then, instead of placing a Band-Aid on a problem that already exists, systems are in place so that errors do not happen in the first place. This approach also takes into consideration the holistic environment of care; the medical personnel, patients, physical environment, and available technology (Dewar, 2010; Peratec, 1995).