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Active errors include events that occur immediately before an accident and are usually caused by people directly interacting with the patient, such as, the nurse or doctor (Latent Errors-Equipment, 2016). In my practice, being a perioperative nurse, we have the surgical “time out” we conduct before each procedure to ensure the correct patient, site, surgery. Ensuring that the patient has informed consent is the first process of being able to conduct a correct timeout. Making sure that the patient’s recent history and physical reflects what the procedure will be and possibly includes, reinforces what the consent states. Wrong site surgeries or incorrect surgery on a patient would be considered active errors, if the nurse does not diligently pay attention to every aspect of the time out.Errors and Adverse Events in Health Care Essay

Latent errors are passive errors that do not have negative effects immediately. They are hidden within technological systems or can be an ill-prepared policy (Latent Errors-Equipment, 2016). In the operating room, latent errors could manifest as implementing new technologies without properly training the staff. This highlights the fact that the staff is unfamiliar with the technology being provided; and that there was bad implementation of said technology by management. This lack of knowledge leads to latent errors. Ways to prevent this would include: an in-service on the new technology and having the representative guide staff in proper use during the surgical procedure.

Although the literature pertaining to errors in health care has grown steadily over the last decade and some notable studies are particularly strong Errors and Adverse Events in Health Care Essay

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Suggested Citation:”2 Errors in Health Care: A Leading Cause of Death and Injury.” Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.×
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methodologically, we do not yet have a complete picture of the epidemiology of errors. Many studies focus on patients experiencing injury and provide valuable insight into the magnitude of harm resulting from errors. Other studies, more limited in number, focus on the occurrence of errors, both those that result in harm and those that do not (sometimes called ”near misses”). More is known about errors that occur in hospitals than in other health care delivery settings.

Synthesizing and interpreting the findings in the literature pertaining to errors in health care is complicated due to the absence of standardized nomenclature. For purposes of this report, the terms error and adverse event are defined as follows:Errors and Adverse Events in Health Care Essay

An error is defined as the failure of a planned action to be completed as intended (i.e., error of execution) or the use of a wrong plan to achieve an aim (i.e., error of planning).18

An adverse event is an injury caused by medical management rather than the underlying condition of the patient. An adverse event attributable to error is a “preventable adverse event.”19 Negligent adverse events represent a subset of preventable adverse events that satisfy legal criteria used in determining negligence (i.e., whether the care provided failed to meet the standard of care reasonably expected of an average physician qualified to take care of the patient in question).20

When a study in the literature has used a definition that deviates from the above definitions, it is noted below.

Medication-related error has been studied extensively for several reasons: it is one of the most common types of error, substantial numbers of individuals are affected, and it accounts for a sizable increase in health care costs.21,22,23 There are also methodologic issues: (1) prescription drugs are widely used, so it is easy to identify an adequate sample of patients who experience adverse drug events; (2) the drug prescribing process provides good documentation of medical decisions, and much of this documentation resides in automated, easily accessible databases; and (3) deaths attributable to medication errors are recorded on death certificates. There are probably other areas of health care delivery that have been studied to a lesser degree but may offer equal or greater opportunity for improvement in safety.Errors and Adverse Events in Health Care Essay

Efforts to assess the importance of various types of errors are currently hampered by the lack of a standardized taxonomy for reporting adverse events, errors, and risk factors.24,25 A limited number of studies focus di-

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Suggested Citation:”2 Errors in Health Care: A Leading Cause of Death and Injury.” Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.×
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rectly on the causes of adverse events, but attempts to classify adverse events according to “root causes” are complicated by the fact that several interlocking factors often contribute to an error or series of errors that in turn result in an adverse event.26,27 In recent years, some progress toward a more standardized nomenclature and taxonomy has been made in the medication area, but much work remains to be done.Errors and Adverse Events in Health Care Essay

The following discussion of the literature addresses four questions:

1. How frequently do errors occur?

2. What factors contribute to errors?

3. What are the costs of errors?

4. Are public perceptions of safety in health care consistent with the evidence?

How Frequently do Errors Occur?
For the most part, studies that provide insight into the incidence and prevalence of errors fall into two categories:

1. General studies of patients experiencing adverse events. These are studies of adverse events in general, not studies limited to medication-related events. These studies are limited in number, but some represent large-scale, multi-institutional analyses. Virtually all studies in this category focus on hospitalized patients. With the exception of medication-related events discussed in the second category, little if any research has focused on errors or adverse events occurring outside of hospital settings, for example, in ambulatory care clinics, surgicenters, office practices, home health, or care administered by patients, their family, and friends at home.Errors and Adverse Events in Health Care Essay

2. Studies of patients experiencing medication-related errors. There is an abundance of studies that fall into this category. Although many focus on errors and adverse events associated with ordering and administering medication to hospitalized patients, some studies focus on patients in ambulatory settings.

Adverse Events
An adverse event is defined as an injury caused by medical management rather than by the underlying disease or condition of the patient.29 Not all, but a sizable proportion of adverse events are the result of errors. Numerous

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Suggested Citation:”2 Errors in Health Care: A Leading Cause of Death and Injury.” Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.×
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studies have looked at the proportion of adverse events attributable to medical error. Due to methodologic challenges, far fewer studies focus on the full range of error—namely, those that result in injury and those that expose the patient to risk but do not result in injury.Errors and Adverse Events in Health Care Essay

The most extensive study of adverse events is the Harvard Medical Practice Study, a study of more than 30,000 randomly selected discharges from 51 randomly selected hospitals in New York State in 1984.30 Adverse events, manifest by prolonged hospitalization or disability at the time of discharge or both, occurred in 3.7 percent of the hospitalizations. The proportion of adverse events attributable to errors (i.e., preventable adverse events) was 58 percent and the proportion of adverse events due to negligence was 27.6 percent. Although most of these adverse events gave rise to disability lasting less than six months, 13.6 percent resulted in death and 2.6 percent caused permanently disabling injuries. Drug complications were the most common type of adverse event (19 percent), followed by wound infections (14 percent) and technical complications (13 percent).31,32

The findings of the Harvard Medical Practice Study in New York have recently been corroborated by a study of adverse events in Colorado and Utah occurring in 1992.33 This study included the review of medical records pertaining to a random sample of 15,000 discharges from a representative sample of hospitals in the two states. Adverse events occurred in 2.9 percent of hospitalizations in each state. Over four out of five of these adverse events occurred in the hospital, the remaining occurred prior to admission in physicians’ offices, patients’ homes or other non-hospital settings. The proportion of adverse events due to negligence was 29.2 percent, and the proportion of adverse events that were preventable was 53 percent.34 As was the case in the New York study, over 50 percent of adverse events were minor, temporary injuries. But the study in New York found that 13.6 percent of adverse events led to death, as compared with 6.6 percent in Colorado and Utah. In New York, about one in four negligent adverse events led to death, while in Colorado and Utah, death resulted in about 1 out of every 11 negligent adverse events. Factors that might explain the differences between the two studies include: temporal changes in health care, and differences in the states’ patient populations and health care systems.Errors and Adverse Events in Health Care Essay

Both the study in New York and the study in Colorado and Utah identified a subset of preventable adverse events that also satisfied criteria applied by the legal system in determining negligence. It is important to note that although some of these cases may stem from incompetent or impaired providers, the committee believes that many could likely have been avoided had better systems of care been in place.

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Suggested Citation:”2 Errors in Health Care: A Leading Cause of Death and Injury.” Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.×
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Extrapolation of the results of the Colorado and Utah study to the over 33.6 million admissions to hospitals in the United States in 1997, implies that at least 44,000 Americans die in hospitals each year as a result of preventable medical errors.36 Based on the results of the New York study, the number of deaths due to medical error may be as high as 98,000.37 By way of comparison, the lower estimate is greater than the number of deaths attributable to the 8th-leading cause of death.Errors and Adverse Events in Health Care Essay

Some maintain these extrapolations likely underestimate the occurrence of preventable adverse events because these studies: (1) considered only those patients whose injuries resulted in a specified level of harm; (2) imposed a high threshold to determine whether an adverse event was preventable or negligent (concurrence of two reviewers); and (3) included only errors that are documented in patient records.39

Two studies that relied on both medical record abstraction and other information sources, such as provider reports, have found higher rates of adverse events occurring in hospitals. In a study of 815 consecutive patients on a general medical service of a university hospital, it was found that 36 percent had an iatrogenic illness, defined as any illness that resulted from a diagnostic procedure, from any form of therapy, or from a harmful occurrence that was not a natural consequence of the patient’s disease.40 Of the 815 patients, nine percent had an iatrogenic illness that threatened life or produced considerable disability, and for another two percent, iatrogenic illness was believed to contribute to the death of the patient.Errors and Adverse Events in Health Care Essay

In a study of 1,047 patients admitted to two intensive care units and one surgical unit at a large teaching hospital, 480 (45.8 percent) were identified as having had an adverse event, where adverse event was defined as “situations in which an inappropriate decision was made when, at the time, an appropriate alternative could have been chosen.”41 For 185 patients (17.7 percent), the adverse event was serious, producing disability or death. The likelihood of experiencing an adverse event increased about six percent for each day of hospital stay.

Some information on errors can also be gleaned from studies that focus on inpatients who died or experienced a myocardial infarction or postsurgical complication. In a study of 182 deaths in 12 hospitals from three conditions (cerebrovascular accident, pneumonia, or myocardial infarction), it was found that at least 14 percent and possibly as many as 27 percent of the deaths might have been prevented.42 A 1991 analysis of 203 incidents of cardiac arrest at a teaching hospital,43 found that 14 percent followed an iatrogenic complication and that more than half of these might have been prevented. In a study of 44,603 patients who underwent surgery between

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Suggested Citation:”2 Errors in Health Care: A Leading Cause of Death and Injury.” Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.×
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1977 and 1990 at a large medical center, 2,428 patients (5.4 percent) suffered complications and nearly one-half of these complications were attributable to error.44 Another 749 died during the same hospitalization; 7.5 percent of these deaths were attributed to error.

Patients who died during surgery requiring general anesthesia have been the focus of many studies over the last few decades. Anesthesia is an area in which very impressive improvements in safety have been made. As more and more attention has been focused on understanding the factors that contribute to error and on the design of safer systems, preventable mishaps have declined.45,46,47,48 Studies, some conducted in Australia, the United Kingdom and other countries, indicate that, today, anesthesia mortality rates are about one death per 200,000–300,000 anesthetics administered, compared with two deaths per 10,000 anesthetics in the early 1980s.49 The gains in anesthesia are very impressive and were accomplished through a variety of mechanisms, including improved monitoring techniques, the development and widespread adoption of practice guidelines, and other systematic approaches to reducing errors.Errors and Adverse Events in Health Care Essay


Lastly, some studies have relied on incident reporting systems to identify and analyze errors. For example, in Australia, 324 general practitioners participating voluntarily in an incident reporting system reported a total of 805 incidents during October 1993 through June 1995, of which 76 percent were preventable and 27 percent had the potential for severe harm.51 These studies provide information on the types of errors that occur but are not useful for estimating the incidence of errors, because the population at risk (i.e., the denominator) is generally unknown.Errors and Adverse Events in Health Care Essay

Medication-Related Errors
Even though medication errors that result in death or serious injury occur infrequently, sizable and increasing numbers of people are affected because of the extensive use of drugs in both out-of-hospital and in-hospital settings. In 1998, nearly 2.5 billion prescriptions were dispensed in U.S. pharmacies at an estimated cost of about $92 billion.52 An estimated 3.75 billion drug administrations were made to patients in hospitals.53

In a review of U.S. death certificates between 1983 and 1993, it was found that 7,391 people died in 1993 from medication errors (accidental poisoning by drugs, medicaments, and biologicals that resulted from acknowledged errors by patients or medical personnel), compared with 2,876 people in 1983, representing a 2.57-fold increase.54 Outpatient deaths due

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Suggested Citation:”2 Errors in Health Care: A Leading Cause of Death and Injury.” Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.×
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to medication errors rose 8.48-fold during the 10-year period, compared with a 2.37-fold increase in inpatient deaths.Errors and Adverse Events in Health Care Essay

Medication Errors in Hospitals
Medication errors occur frequently in hospitals. Numerous studies have assessed the incidence of adverse drug events (ADEs), defined as an injury resulting from medical intervention related to a drug.55 Not all ADEs are attributable to errors. For example, a patient with no history of allergic reactions to drugs, who experiences an allergic reaction to an antibiotic, has suffered an ADE, but this ADE would not be attributable to error. However, an error would have occurred if an antibiotic was prescribed to a patient with a history of documented allergic reactions, because the medical record was unavailable or not consulted. We discuss only those studies of ADEs that identified the subset of ADEs determined to be preventable (i.e., attributable to errors).

In an analysis of 289,411 medication orders written during one year in a tertiary-care teaching hospital, the overall error rate was estimated to be 3.13 errors for each 1,000 orders written and the rate of significant errors to be 1.81 per 1,000 orders.56 In a review of 4,031 adult admissions to 11 medical and surgical units at two tertiary care hospitals, Bates et al. identified 247 ADEs for an extrapolated event rate of 6.5 ADEs per 100 nonobstetrical admissions, and a mean number per hospital per year of approximately 1,900 ADEs.57 Twenty-eight percent were judged preventable.Errors and Adverse Events in Health Care Essay

In a study of patients admitted to coronary intensive care, medical, surgical, and obstetric units in an urban tertiary care hospital over a 37-day period, the rate of drug-related incidents was 73 in 2,967 patient-days: 27 incidents were judged ADEs; 34, potential ADEs; and 12, problem orders.58 Of the 27 ADEs, five were life threatening, nine were serious, and 13 were significant. Of the 27 ADEs, 15(56 percent) were judged definitely or probably preventable. In a study of prescribing errors detected and averted by pharmacists in a 631-bed tertiary care teaching hospital between July 1994 and June 1995, the estimated overall rate of errors was 3.99 per 1,000 medication orders.59

Children are at particular risk of medication errors, and as discussed below, this is attributable primarily to incorrect dosages.60,61 In a study of 101,022 medication orders at two children’s teaching hospitals, a total of 479 errant medication orders were identified, of which 27 represented potentially lethal prescribing errors.Errors and Adverse Events in Health Care Essay

the two institutions, 4.9 and 4.5 errors per 1,000 medication orders. The error rate per 100 patient-days was greater in the pediatric intensive care units (PICUs) than in the pediatric ward or neonatal intensive care units, and the authors attribute this to the greater heterogeneity of patients cared for in PICUs and the broad range of drugs and dosages used. In a four-year prospective quality assurance study, 315 medication errors resulting in injury were reported among the 2,147 neonatal and pediatric intensive care admissions, an error rate of one per 6.8 admissions.63 The frequency of iatrogenic injury of any sort due to a medication error was 3.1 percent—one injury for each 33 intensive care admissions.

Not surprisingly, the potential for medication-related error increases as the average number of drugs administered increases. In a prospective cohort study of 4,031 adult admissions to 11 medical and surgical units in two tertiary care hospitals (including two medical and three surgical ICUs), the rate of preventable ADEs and preventable potential ADEs in ICUs was 19 events per 1,000 patient-days, nearly twice the rate of non-ICUs.64 When adjusted for the number of drugs used in the previous 24 hours or ordered since admission, there were no differences in error rates between ICUs and nonICUs.Errors and Adverse Events in Health Care Essay

Current estimates of the incidence of medication errors are undoubtedly low because many errors go undocumented and unreported.65,66,67,68 For example, in a study of patients admitted to five patient care units at a tertiary care hospital during a six month period in 1993, it was found that incident reports were filed with the hospital’s quality assurance program or called into the pharmacy hotline for only three of the 54 people experiencing an adverse drug event.69

Some errors are also difficult to detect in the absence of computerized surveillance systems. In a study of 36,653 hospitalized patients, Classen et al. identified 731 ADEs in 648 patients, but only 92 of these were reported by physicians, pharmacists, and nurses.70 The remaining 631 were detected from automated signals, the most common of which were diphenhydramine hydrochloride and naloxone hydrochloride use, high serum drug levels, leukopenia, and the use of phytonadione and antidiarrheals.

Medication Errors in Ambulatory Settings
There is evidence indicating that ADEs account for a sizable number of admissions to inpatient facilities, but we do not know what proportion of these ADE-related admissions are attributable to errors. Errors and Adverse Events in Health Care Essay

that between three and 11 percent of hospital admissions were attributable to ADEs.71 A review of 14 Australian studies published between 1988 and 1996 reported that 2.4 to 3.6 percent of all hospital admissions were drug related, and between 32 and 69 percent were definitely or possibly preventable. Drug groups most commonly involved were cytotoxics, cardiovascular agents, antihypertensives, anticoagulants, and nonsteroidal anti-inflammatory drugs.72

ADEs also result in increased visits to physician offices and emergency departments. In an analysis of 1,000 patients drawn from a community of-rice-based medical practice who were observed for adverse drug reactions, adverse effects were recorded in 42 (4.2 percent), of which 23 were judged to be unnecessary and potentially avoidable.73 In an analysis of 62,216 visits to an emergency department by patients enrolled in a health maintenance organization (HMO), it was found that 1,074 (1.7 percent) were related to medication noncompliance or inappropriate prescribing.Errors and Adverse Events in Health Care Essay

There is a sizable body of literature to document the incidence of patient noncompliance with medication regimens, but less is known about the proportion of noncompliance attributable to medical error (defined as accidental or unintentional nonadherence to a therapeutic program) as opposed to intentional noncompliance. In a meta-analysis of seven studies, Sullivan et al. estimate that 5.5 percent of admissions can be attributed to drug therapy noncompliance, amounting to 1.94 million admissions and $8.5 billion in hospital expenditures in 1986.75 Similar results were obtained by Einarson in a meta-analysis of 37 studies published between 1966 and 1989, which found that hospital admissions caused by ADEs, resulting from noncompliance or unintentionally inappropriate drug use, ranged from 0.2 to 21.7 percent with a median of 4.9 percent and a mean of 5.5 percent.76 Patient noncompliance is clearly an important quality issue, but it should be emphasized that we do not know the extent to which noncompliance is related to errors.Errors and Adverse Events in Health Care Essay

Factors that Contribute to Errors
Studies of Adverse Events
Patient safety problems of many kinds occur during the course of providing health care. They include transfusion errors and adverse drug events; wrong-site surgery and surgical injuries; preventable suicides; restraint-related injuries or death; hospital-acquired or other treatment-related infections; and falls, burns, pressure ulcers, and mistaken identity. Leape et al.

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Suggested Citation:”2 Errors in Health Care: A Leading Cause of Death and Injury.” Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.×
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Page 36

have characterized the kinds of errors that resulted in medical injury in the Medical Practice Study as diagnostic, treatment, preventive, or other errors (see Box 2.1).Errors and Adverse Events in Health Care Essay

More than two-thirds (70 percent) of the adverse events found in this study were thought to be preventable, with the most common types of preventable errors being technical errors (44 percent), diagnosis (17 percent), failure to prevent injury (12 percent) and errors in the use of a drug (10 percent). The contributions of complexity and technology to such error rates is highlighted by the higher rates of events that occur in the highly technical surgical specialties of vascular surgery, cardiac surgery, and neurosurgery. In hospitals, high error rates with serious consequences are most likely in intensive care units, operating rooms and emergency departments.

Early studies on patients’ safety in the 1950s considered medical errors largely “inevitable diseases of medical progress” [1], and scientific literature often referred to them as “the price paid for modern diagnosis and treatment” [2]. Patients’ insecurity regarding the quality of services provided grows constantly, as mortality and morbidity caused by medical errors demonstrate increasing trends throughout the ages, particularly in countries with deficient social and scientific maturity. In developed countries, one in 10 patients experiences adverse events during hospitalization, according to World Health Organization (WHO). These events could have been predicted and prevented. Moreover, the risk in developing countries is 20 times higher, compared to developed countries [3]. Two categories of errors, which are mentioned subsequently, are the most reported the latest years.Errors and Adverse Events in Health Care Essay

“Communication errors” between healthcare professionals could negatively have an effect on patient safety throughout routine care and even more so during emergency care and in code situations. Training and recent procedures have been established to decrease communication errors [4]. Errors and Adverse Events in Health Care Essay

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