Reducing Medical Errors and Adverse Events

Abstract

Medical errors account for ∼98,000 deaths per year in the United States. They increase disability and costs and decrease confidence in the health care system. We review several important types of medical errors and adverse events. We discuss medication errors, healthcare-acquired infections, falls, handoff errors, diagnostic errors, and surgical errors. We describe the impact of these errors, review causes and contributing factors, and provide an overview of strategies to reduce these events. We also discuss teamwork/safety culture, an important aspect in reducing medical errors.

The Impact of Rudeness on Medical Team Performance: A Randomized Trial

“…However, results from the mediation analyses indicate that aside from any effects that rudeness may have on individual cognitive processing, rudeness exposure may also weaken the very collaborative processes (informationsharing and help-seeking) 36,37 that might otherwise allow teams to compensate for the diminished performance of 1 or more of their members. 4,34 Overall, we found rudeness explained 52% of the variance in diagnostic performance and 43% of the variance in procedural performance. In comparison, recent meta-analyses found that structural factors such as the presence/absence of computerized order entry systems explained just 12.5% of the variance in medication error 38 and chronic sleep loss explained just 23% of the variance in physician clinical performance.…”

“…[28][29][30][31] For example, recent studies estimate that patients are exposed to at least 1 medication error per day 4,32 and report numerous cases of retained surgical items. 4,33 We suspect that 1 major reason for this gap is because many of the improvements were directed at refining systems and technologies 11,14 while neglecting human/relational factors. 4,34 Our results highlight the potential role of human interaction in iatrogenic events, indicating that occurrence of even a mild rudeness can have adverse consequences on the diagnostic and procedural performance of NICU team members.…”

“…4,33 We suspect that 1 major reason for this gap is because many of the improvements were directed at refining systems and technologies 11,14 while neglecting human/relational factors. 4,34 Our results highlight the potential role of human interaction in iatrogenic events, indicating that occurrence of even a mild rudeness can have adverse consequences on the diagnostic and procedural performance of NICU team members. Indeed, many of the ratings received by members of the rudeness group were between 2 (poor) and 3 (moderate) (Tables 2 and 3), suggesting that the judges saw evidence of potentially harmful practice.…”

“…1 Iatrogenic events include diagnostic error or delay, dosing and procedural errors, and failure to identify and respond to diagnostic or treatment errors in a timely manner. [1][2][3][4] In nearly 4% of hospitalizations, the treatment itself causes morbidity, with one-half of these events being preventable and 14% resulting in death. 5,6 Studies suggest that the rate of iatrogenic events among hospitalized pediatric patients is substantially higher, and that the critically ill, such as those hospitalized in NICUs, are at particular risk.…”

Biomedical Simulation: Evolution, Concepts, Challenges and Future Trends

“…Previous reports from the Institute of Medicine, 2,3 the National Healthcare System, 4 and other publications [5][6] attribute 70% -80% of these errors to poor soft skills, namely communication, leadership, team work, among others. These reports have clear recommendations on the use of simulation to promote patient safety:…”