Medical Errors: Causes, Impacts and Prevention

Background

When thinking about topics and drawing up ethical implications the first topic that comes to mind is medical errors. Medical errors are false or incomplete diagnosis and/or treatment of a disease, injury, syndrome, behavior, infection, or other ailment. Medical errors have been one of the top causes for deaths in the country for years. Many families and friends have lost loved ones due to healthcare professionals and their inability to provide the proper care for the patient at hand. According to Carver N, Hipskind JE, “the most recent study in 2013 suggested the numbers range from 210,000 to 440,000 deaths per year. The latter number would make it the third leading cause of death after heart disease and cancer (2019)”. Individuals from all of the world lost their lives to improper transfusions, burns, falls, mistaken patient identities, the lack of crucial information when needed to influence prescribing decisions, poor coordination of medication orders for transfer of care, over treatment, wrong site surgery, lack of appropriate communication of test results, etc. Throughout my paper I will give examples and explain the reasons why medical errors happened and give suggestions on how they can be prevented and repaired.

Define the Problem

 With medical errors being on of the top reasons for deaths in the United States we must first investigate why and how errors are occurring without lack of knowledge. When a patient is checked into a clinic, nursing home or hospital setting they must first go through the process of documentation in order to ensure the safety and proper care for the correct patient. In accordance with, Always Culture “Human problems occur when standards of care, policies, processes, or procedures are not followed properly or efficiently. Some examples include poor documentation and labeling of specimens. Knowledge-based errors also occur when individuals do not have adequate knowledge to provide the care that is required at the time it is needed (2019)”. In hospitals especially, patient’s information passes through multiple departments and evaluation checks to ensure safety. Furthermore, for an error to occur it must be due to lack a care. Anyone could commit medical errors that impact a patient’s outcome; nurses, pharmacists, administrators, patients themselves, their families and friends. With some many individuals someone should have caught on to a mistake and handled it before the patient’s safety and health was in jeopardy. The main problem with medical errors is lack of communication. Whether it’s a medical error: the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim, serious error: an error that causes permanent injury or transient but life-threatening harm. minor error: an error that causes harm that is neither permanent nor potentially life threatening. near misses: an error that could have caused harm but did not either by chance or timely intervention. A mistake was made and we as healthcare professional must find a concrete way to prevent mistakes like this from occurring. With knowing that healthcare professional are humans and they are not prefect so mistakes will occur; having someone die due to something that could have been prevented is what I want us as healthcare workers to focus on. So, the problem is “How can we as healthcare professionals prevent medical errors in all healthcare settings?”

Literature Review

If I want healthcare professionals to not make errors I would first make sure that they are performing there daily task and duties correctly. According to our text “Duty refers to a legal obligation the defendant owes to the plaintiff. Although in some cases there are very precise standards by which to determine duty, most commonly it is expressed as a general obligation to act with due care—in other words, to conduct oneself as a reasonably prudent person would in similar circumstances. A breach of duty imposes liability if it results in injury to property or another person (Showalter, 2019).” When healthcare professionals sign on to a task it is there job to operate under their duty and do what it takes (as long as its legal) to ensure someone’s health improve. Everyone in healthcare environments are responsible for doing their part in making sure someone’s visit to their facility is great; whether it’s the deck assistant or physician everyone plays a part and as long as they commit to their duties there shouldn’t be any negligent.  As previous stated, healthcare professionals are human-beings and as a human I know that no one is perfect; so, there should always be room for error but how much? How many times does something have to occur before someone puts their foot down and address the situation about medical errors? While medical errors like: Infection, Medication, Error Delayed Diagnosis, and Misdiagnosis are things that doctors, and nurses are supposed to protect you from in their line of duties. Those statements alone can’t not constitute negligence. According to Showalter “The physician–patient relationship is based on contract principles because the physician agrees to provide treatment in return for payment. Professional liability can arise if this contract is breached. In the absence of a contract between physician and patient, the law usually imposes no duty on the physician to treat the patient, although it may impose other duties on the physician (2019).” Negligence is a medical malpractice that can also be based on breach of contract or the commission of intentional torts. After reading about everything being contract based and if you can’t proof negligence for medical errors what do you do? How do you take an imperfect person and make them not make any mistakes? The answer is… you don’t! we must for ask why? Why are mistakes being made and how can we prevent them from occurring.

Problem Analysis

Medical errors are very common. Even in the best hospitals in the country, mistakes can happen. But, that doesn’t mean you should avoid getting the necessary medical treatment for fear of something going wrong. We must identify the causes of medical errors and state how they can be prevented. According to MicroHealth, the top ten medical errors are: misdiagnosis, treating wrong patient, air bubbles in blood, infections, lab errors, equipment failures, patients falls, and lack of coordinated care and wrong medication (2019). Those ten medical errors alone killed millions of people. Now, we must look at what they all have in common. All these errors have burned out, over-whelmed, sleep deprived employees. After reading about all the medical errors, looking into the doctor to patient ratio in rural and low-income communities; I was starting to see a pattern. We are currently experiencing a shortage in staff in most hospitals and not only is the waiting room, nursing homes, but the clinics as well are all poorly staffed and sufficiently outnumbered. According to the Healthcare Financial Management Association, “Researchers and healthcare workforce training leaders testified at the Senate Health, Education, Labor and Pension (HELP) Committee about the extent and concentrations especially in rural areas of healthcare workforce shortages. Existing shortages include the need for 13,800 additional primary care physicians in areas especially rural that are designated as health professional shortage areas, according to estimates of the Health Resources and Services Administration (HRSA). Signs of a worsening situation include projected shortages of 20,000 primary care physicians by 2025, according to HRSA, and 42,600 to 121,300 physicians by 2030, according to the Association of American Medical Colleges (2019).” I believe the major problem were experiencing with medical errors are due to lack of staff, lack of double checking results, extreme multi-tasking (which causes for healthcare professionals to not be as sanitary as they should hints causing infection), and tiredness.

Solutions and Implementation

As a healthcare professional you go to work every day with the intensions on helping change someone’s life. When they accepted the job, they knew that it’s their responsible to try to help out as much as possible while at work. Well that’s what most healthcare working are doing today. While the United States is experiencing a staffing shortage. Professionals are working double shifts, missing breaks, coming in on their days off and its exhausting. When a person become exhausted they miss little things that they would have noticed if they were at the top of their game. While trying to juggle more patients, care for them, and making sure they don’t miss anything on their charts sometimes things can become difficult to handle; causing for medical errors to occur. It’s not always a lack in knowledge; sometimes its just a lack in attention or focus. Doctors everyday have to be In-top shape due to the number of patients they have to attend to, trying their best to ensure the care and safety of others is their number one priority. So how can we stop the errors. First, all health care organizations should follow the event policies and procedures to avoid patient injury and malpractice.

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Secondly, the right identification of the patient helps to ensure that the medical personnel has the proper information of the patient. The information is very important when it comes time for the doctor to prescription the medication to each the patient. All of the patient information that should be well seized, for example: the name, date that they were born, contact information, their ID number, billing and payment information, and blood group types are few among others that should be captured. All details are crucial and will help with administration of the correct dosage prescribed by the doctor. Having the correct patient information helps to reducing the risk of patients getting the wrong prescription. The risks that the patients face would include death, long term life suffering, and disability among others. The chances of these outcomes happening are very high since many patients are being attended. The risks could change the life of the victim permanently. Correct identification should be given priority as it’s an essential first step that facilitates the treatment of the patient (Excellence, 2013).

Then, the prescribed medication should be well labeled and double checked. Well, labelling will ensure that the pharmacist gives the correct prescription to the patient. It’s the responsibility of the medical facility to ensure that the medication is well stored in a cool, dry place that will not lead to destroying of its quality. It’s also important to sterilize the various medical equipment and tools. Sterilizing them helps to reduce the risk of passing on infections to other patients or even to oneself. The medication should also be stored in well labeled and tightened containers. The containers will help to ensure that there are no foreign materials that get into the containers. Foreign materials in medical containers may trigger reactions that lead to the development of toxic substances that may cause patient poisoning. To control it, it’s important to ensure that the medication is stored in a well-organized station that is well lit. The light will help one identify the right medicine quickly for administration (American Diabetes Association, 2013).

References

• AddEvent. (2018, June 29). The 8 Most Common Root Causes of Medical Errors. Retrieved December 15, 2019, from https://alwaysculture.com/hcahps/communication-medications/8-most-common-causes-of-medical-errors/.
• American Diabetes Association. (2013). Standards of medical care for patients with diabetes mellitus. Puerto Rico Health Sciences Journal, 20(2).
• Excellence, B. P. (2013). The Joint Commission announces 2014 national patient safety goal. Joint Commission Perspectives.
• Carver N, Hipskind JE. Medical Error. [Updated 2019 May 15]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430763/
• Daly, R. (n.d.). Healthcare Workforce Shortage Worsening: Senators. Retrieved from https://www.hfma.org/topics/news/2018/05/60811.html.
• Showalter, J. S. (n.d.). VitalSource Bookshelf Online. Retrieved from https://online.vitalsource.com/#/books/9781567938777/pageid/134.
• Showalter, J. S. (n.d.). VitalSource Bookshelf Online. Retrieved from https://online.vitalsource.com/#/books/9781567938777/cfi/134!/4/4@0.00:37.2
• Top 10 Reasons for Medical Errors. (2019, May 15). Retrieved from https://www.microhealthllc.com/top-ten-reasons-for-medical-errors-2/.