medical error

Introduction

The medical ethics principle of disclosing medical errors is fidelity.

Classification

• close calls, near misses
  • catching wrong medicine before given to patient
• adverse event
  • falls, medication error, etc
• sentinel event
  • results in death, serious physical or psychologic injury
  • wrong site surgery
  • suicide
  • must be reported immediately

Epidemiology

• most frequent errors are errors associated with:
  • laboratory & radiologic testing (44%)
    • failures or delays in test ordering, performance
    • appropriate clinician interpretation
    • follow-up of abnormal test results
  • clinician assessment (32%)

Management

• minimize or eliminate harm
  • closed loop communication to reduce errors in medication & its administration
• filing of incident report as required by institution
• physicians must inform patients about medical errors if the information will impact on patient's present & future health& well-being
• patients want to be informed of all medical errors, regardless if there was an adverse outcome
  • this optimizes informed decision making, promotes trust, may reduce stress, & may mitigate risk of litigation
  • provide an early, open, honest account of the error & apologize formally to the patient
  • telling the truth shortly after the error is discovered is ethically obligatory & is the accepted standard of care.
• inform patient that steps are being taken to prevent future errors

Notes

• concerns that disclosing an error promotes litigation are not supported by data
• 3rd leading cause of death in U.S. after heart disease & cancer

More specific terms

• diagnostic error (missed diagnosis)

Additional terms

• harm