Understanding Error

Improved communication strategies with both parties can lead to positive effects and improved health care outcomes. Discussing the importance of communication in a team setting, Lingard et al (2005), explain that, “When medical errors occur, they are regularly traced back to breakdowns in communication between members of the healthcare team.”

Reason’s (2000) two different types of errors
Active: Unsafe acts…arising primarily from aberrant mental processes such as forgetfulness, inattention, poor motivation, carelessness, negligence, and recklessness (consequences are seen immediately)
Systematic: Seen as consequences rather than causes, having their origins not so much in the perversity of human nature as in ‘upstream’ systemic factors (consequences are seen over time)

Interprofessional education and collaborative care are intended to address both types of errors:

  • Errors that result from mental lapses—improving each other’s skills, processes, abilities, and attentiveness. Members of a fully functional team welcome the observations, suggestions, and even immediate correction of the other team members.
  • Errors that manifest over time, as a result of latent issues that remain unaddressed over an extended period of time—improving the system in which health care is delivered. Members of a team develop a common language to assure clear communication among themselves and their patients. They respect each other’s interventions and reinforce and apply them so that care is seamless and consistent. They actively seek out and apply best practices.

On a team, everyone is responsible for everything that the team does. This produces mutual accountability. That, in turn, leads to a culture that avoids blaming and defensiveness, and strives to continuously improve.

How Much Error is There?
The definitive 2000 Institute of Medicine report, To Err is Human, claim that medical errors result in between 44,000 and 98,000 deaths per year in America’s hospitals.
Below are figures from 2008 (Van Den Bos, Rustagi, Gray, Halford, Ziemkiewicz, & Shreve, 2011):

  • Number of medical injuries: 6,319,487
  • Number of medical errors: 1,503,323
  • Number of medical errors resulting in injuries (greater than 90% probability of error): 810,898

Error vs. Injury
It is crucial not to equate, or confuse, medical error with medical injury. The two terms are defined as follows:

Medical Error: “A preventable adverse outcome that results from improper medical management (a mistake of commission) rather than from the progression of an illness resulting from lack of care (a mistake of omission)” (Van Den Bos, Rustagi, Gray, Halford, Ziemkiewicz, & Shreve, 2011)

Medical Injury: “Medical care with an adverse outcome, [which] could be due to medical error or to unavoidable complications, [and includes] a wide range of outcomes, from a mild allergic reaction to a drug all the way to death” (Van Den Bos, Rustagi, Gray, Halford, Ziemkiewicz, & Shreve, 2011)

Though it should be a goal to eliminate all errors, it is most important to focus on addressing the errors (and their causes) that result in medical injury.

Cost and Consequences of Error in Health Care
In 2008, medical errors cost the United States between $17.1 billion (Van Den Bos, Rustagi, Gray, Halford, Ziemkiewicz, & Shreve, 2011) and $19.5 billion (Andel, Davidow, Hollander, & Moreno, 2012).

How does Teamwork Affect Patient Safety?
According to Firth-Cozens (2001), teams affect patient safety in the following ways:

  • Teams enhance thoroughness and attention to detail
  • Facilitate interagency cooperation
  • Input from all members of the care team
  • Input from multiple health professionals, relatives, and the patients
  • Regular team discussions and feedback improve detection, treatment, and patient follow-up
  • Reduction in fatigue
  • Lower stress levels

References
Andel, C., Davidow, S.L., Hollander, M., & Moreno, D.A. (2012). The economics of health care quality and medical errors. Journal of Health Care Finance, 39(1), 1-12
Firth-Cozens, J. (2001). Cultures for improving patient safety through learning: the role of teamwork. Quality in Health Care, 10(suppl II), ii26-ii31
Kohn, L.T., Corrigan, J.M., & Donaldson, M.S. (eds). (2000). To Err is Human: Building a Safer Health System. Washington, D.C.: National Academy Press
Lingard, L. et al. (2005). Getting teams to talk: development and pilot implementation of a checklist to promote interprofessional communication in the OR. Quality and Safety in Health Care, 14, 340-346. doi: 10.1136/qshc.2004.012377
Reason, L. (2000). Human error: models and management. BMJ Education and Debate, 320, 768-770. doi:http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1117770/pdf/768.pdf
Van Den Bos, J., Rustagi, K., Gray, T., Halford, M., Ziemkiewicz, E., & Shreve, J. (2011). The $17.1 billion problem: the annual cost of measurable medical errors. Health Affairs, 30(4), 596-603. doi: 10.1377/hlthaff.2011.0084