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:
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):
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:
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