This paper will cover medical errors and how Continuous Quality Improvement can address them. Health care managers have addressed the issue of medical errors for many years. Medical errors can be caused by lack or communication and leadership. Quality improvement in the health care environment is a hot topic and managers are researching ways in which they can increase the quality of care that a patient receives. The quality of care that a patient receives can be the determining factor as to whether they live or die. It is critical that managers develop policies and implement control measure to control the rise of medical errors.
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Attention to medical errors escalated over five years ago with the release of a study from the Institute of Medicine (IOM), which found that between 44,000 and 98,000 Americans die each year in U.S. hospitals due to preventable medical errors (Kaiseredu, 2010). Hospital errors rank between the fifth and eighth leading cause of death, killing more Americans than breast cancer, traffic accidents or AIDS. Serious medication errors occur in the cases of five to 10 percent of patients admitted to hospitals. These numbers may understate the problem because they do not include preventable deaths due to medical treatments outside of hospitals (kaiseredu, 2010).
Health care managers, along with the Food and Drug Administration, have study the medical error reports to determine the cause of errors. Medical errors are one of the leading causes as to why health care has declined. To improve healthcare managers must determine how to decrease the mortality rates. Managers can determine this by studying and analyzing medical reports. These reports provided managers with detailed information on what procedure was being conducted or what medication the patient was administered. In a study by the FDA that evaluated reports of fatal medication errors from 1993 to 1998, the most common error involving medications was related to administration of an improper dose of medicine, accounting for 41% of fatal medication errors. Giving the wrong drug and using the wrong route of administration each accounted for 16% of the errors. Almost half of the fatal medication errors occurred in people over the age of 60. Older people may be at greatest risk for medication errors because they often take multiple prescription medications (Stoppler & Marks, 2010).
History has shown that many surveys and research studies have been conducted, so that providers can learn where and why mistakes are being made. Once providers have a clear understanding, they can implement control measure to insure these mistakes do not occur. National Patient Safety Foundation Survey: The National Patient Safety Foundation (NPSF) commissioned a phone survey in 1997 to review patient opinions about medical mistakes. The findings showed that 42% of people believed they had personally experienced a medical mistake. In these cases, the error affected them personally (33%), a relative (48%), or a friend (19%) (Wrongdiagnosis, 2010). Patients that were given the survey have experienced the following medical errors:
Misdiagnosis (40%),
Medication error (28%),
Medical procedure error (22%),
Administrative error (4%),
Communication error (2%),
Incorrect laboratory results (2%),
Equipment malfunction (1%), and
Other error (7%).
Patient safety should be the number one concern for health care organizations. Health care managers are held accountable for ensuring that patients are provided with quality care. They are also accountable for the patients that are injured or die due to a provider’s medical error. The health care industries along with scientific researchers have developed tools in which the quality of care can be measured. Organizations can use these tools to determine if effective care is being provided. Once they have determined the level of care they are providing, they can educate providers on what they are doing both wrong and right. The most common method used to determine the quality of care, is through the use of surveys. Health care organizations can provide staff and patients with surveys to determine what areas the organization can improve and sustain. These surveys will not be provided to every patient the provider has treated but only a selected few will be surveyed.
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Quality measurement in the healthcare industry requires a large amount of resources and funding. Researchers will most likely use methods that have worked before and have provide them with data; they could use to enhance the level of care the organization is providing. Healthcare researchers are constantly trying to find ways in which the completely eliminate medical errors. Due to the continuous cycle of experienced providers leaving and new providers being hired, medical errors in many cases will never be eliminated. Health care organizations can however implement the necessary control measures to ensure that patients are not misdiagnosed or the wrong limb is not amputated (Cohen, 2007).
Healthcare organizations can decrease medical errors by establishing a continuous quality improvement plan that calls for the development of a multidisciplinary team to research and investigate the causes of medical errors. The Department of Veteran Affairs uses a CQI model developed by the Joint Commission to reduce the number or medical mistakes made by providers. Joint Commissions surveys all the Veteran Affairs Medical centers to see whether their staff is following the medical policies and regulations in providing quality care.
Joint Commission has also established policies regarding how health care organizations will report and handle sentinel events. A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase, “or the risk thereof” includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome. Such events are called “sentinel” because they signal the need for immediate investigation and response (Jointcommission, 2010).
In conclusion medical errors can occur at anytime while a patient is receiving care. It is important that health care providers communicate and provide education to their staff on reducing the number of medical errors, the facility has encountered. Medical errors can lead to the organization being sued by the patient or the patient family member. Law suites can be devastating for any organization to go through and can reduce the amount of funds that have been allotted to providing quality care. Therefore it is important that medical errors are reduced and even eliminated.
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