Mistakes are not something that we usually associate with the medical field. But medical mistakes do happen mainly because medical professionals are only humans who can err. In medical terms, they are called iatrogenic events, defined as unintended harm or suffering caused by health care. Medical mistakes are usually something that people associate with health care in developing and low-income countries where they lack the right infrastructure and trained personnel. The fact is, a lot of medical mix ups and mistakes in hospitals and clinics occur all over the world, including Europe and North America. One gets to wonder how many medical misadventures go unreported!
Medical misadventures are classified as Adverse Drug Events, Hospital Acquired Infections and Surgical Mistakes.
(1) Adverse Drug Events (ADEs) or medication mix ups are perhaps the most common. One of the most well-publicized medication mix ups was the case of Quaid twins who received the wrong dose of heparin. The newborn babies were reportedly given an excessive dose which was up to 1,000 times the normally prescribed dose. Fortunately, the error was detected early enough so that the Quaid twins, plus several other babies, could be saved. One must not forget that there are other adverse events besides drugs, as evidenced by the recently highly publicized excessive radiation exposure incident in California.
A study in France revealed that in the period January and September 2005, 267 cases of iatrogenic events happened to 116 newborn babies. 34% were preventable, 29% were severe, 2 cases were fatal, 34 cases were due to drugs and 19 cases were identified as medical errors. The study concluded that iatrogenic events occur frequently and are often serious in neonates, especially in infants of low birthweight.
A study in the US revealed that for every 100 children hospitalized, 11 drug-related mistakes can occur. About 500,000 children in the US suffer from drug mix ups. Less than 4% of medical mix ups are reported. And according to the 1991 Harvard Medical Practice Study, there is a 6.5% rate of ADEs among adult inpatients, 33% of which were considered preventable.
(2) Hospital-Acquired Infections (HAIs). Hospitals are not the cleanest of environments and all are actually the breeding ground for dangerous bugs. All too often, patients get the so-called Hospital-Acquired Infection (HAI) also known as nosocomial infection or healthcare-associated infections. According to the CDC, about 100,000 people die of HAIs due to antibiotic-resistant bacteria.
In the US, the incidence of HAIs exceeds 2 million cases a year and an estimated expenditure of more than $4.5 billion is attributed to HAIs. Most are detected 48 hours after admission to the hospital. In a survey of patients from a pediatric ICU between 1992 and 1997, bacterial and fungal infections were reported as follows: Bloodstream infections – 28% Ventilator-associated pneumonia – 21% Urinary tract infection (UTI) – 15% Lower respiratory infection – 12% Gastrointestinal, skin, soft tissue, and cardiovascular infections – 10% Surgical-site infections – 7% Ear, nose, and throat infections – 7%. In fact, a French study on newborns reported that the most common medical mistakes reported were due to infections contracted within the hospitals.
HAIs cannot be fully attributed to mistakes made by health professionals but hospital staff are instrumental in preventing them. Risk factors for HAIs include:
– Iatrogenic including pathogens on the hands of medical personnel, invasive procedures such as intubation and extended ventilation, indwelling vascular lines and urine catheterization, and antibiotic use and prophylaxis.
– Organizational including contaminated air-conditioning systems, contaminated water systems, and staffing and physical layout of the facility. Some places in a hospital are more infectious than others. According to a 1986 to 1988 survey by the National Nosocomial Infections Surveillance (NNIS) System of the Centers for Disease Control and Prevention (CDC), the highest infection rates occur at the intensive care units, especially the burn ICU, the neonatal ICU, and the pediatric ICU. Newborn babies, especially those who are premature with low weight weights are more susceptible to HAIs.
– Patient risk factors include the severity of illness, underlying immunocompromised state, and length of stay.
(3) Surgical mistakes. And it is not just about leaving a surgical sponge inside a patient. The most frequent surgical mistakes are wrong site surgeries. In 2001, the Joint Commission documented 150 cases of wrong site, wrong person or wrong procedure surgery. 76% involved surgery on the wrong body part or site; 13% involved surgery on the wrong patient and 11% involved the wrong surgical procedure.
A 2003 report which surveyed 1,165 hand surgeons was just as startling. 16% reported that they had prepared to operate on the wrong site but then noticed the error prior to the incision and 21% reported performing wrong-site surgery at least once. One in 27,686 procedures was performed in the wrong site. The three most common locations of wrong-site surgery were the fingers, hands, and wrists. 9% of patients suffered from permanent disability.
Medical errors go hand in hand with overcrowding, overworked staff and cost cutting.
(1) Overcrowding. Many hospitals, especially in large urban areas, are overcrowded and we are not even talking about the flu season, nevermind H1N1 or another pandemic. There are more patients than the hospital staff and hospital resources can handle. Because of overcrowding health professionals cannot spend enough time with patients. Researchers at the Massachusetts General Hospital (MGH) and Brigham and Woman’s Hospital (BWH) report that hospitals with high occupancy rates have increased workloads and higher patient-to-nurse ratios which are associated with increased incidence of adverse events.
(2) Overworked staff. Several studies have linked medical errors to long working hours and burnout especially among interns and residents. In December 2008, the Institute of Medicine released a report that proposed revisions to the duty hours and workload of medical residents. According to Michael M.E. Johns, chancellor, Emory University, Atlanta and chairman of the committee which prepare the report: “Fatigue, spotty supervision, and excessive workloads all create conditions that can put patients’ safety at risk and undermine residents’ ability to learn. The report did not recommend the reduction of the 80-hour working week because it would most likely cost a lot of money and cause understaffing in hospitals. However, the proposed changes addressed the residents’ workload, including the number of hours that residents can work without sleep (16 hours), more days off, and restrictions on moonlighting. In another study, researchers at the Mayo Clinic reported that distress and fatigue among medical residents contribute greatly to medical errors.
(3) Cost-cutting. The MGH-BWH study reported that efforts to meet two primary challenges facing hospitals today – reducing costs and improving patient safety – may work against each other. The researchers investigated four teaching hospitals for 12 months. According to the lead author Dr. Joel Weissman “While financial and political pressures to make health care more efficient are leading to increased hospital occupancy and greater patient turnover, patients and policymakers are quite rightly demanding that health delivery systems be made safer. Our study suggests that pushing efficiency efforts to their limits could be a double-edged sword that may jeopardize patient safety.”
So what’s the health care industry doing to clean up its act? In 1999, the Institute of Medicine released the groundbreaking report To Err is Human: Building a Safer Health System. According to the report “Beyond their cost in human lives… errors…are costly in terms of loss of trust in the health care system by patients and diminished satisfaction by both patients and health professionals.”
The good news is that awareness of medical errors has increased both among health providers and patients. Hospitals, medical professionals, advocacy and watchdog groups are making strides in improving the safety of health care.
The Commission on Accreditation of Healthcare Organizations (JCAHO) has launched a number of initiatives to address patient safety especially infection control in hospital settings.
The Agency for Healthcare Research and Quality (AHRQ) encourages patients to prevent medical errors by asking questions. In fact, it has produced several TV spots urging patients to “take charge of their health” and ask questions just like they would ask questions about the food they order in a restaurant. The AHRQ recommends the following 10 questions: What is the test for? How many times have you done this? When will I get the results? Why do I need this surgery? Are there any alternatives to surgery? What are the possible complications? Which hospital is best for my needs? How do you spell the name of that drug? Are there any side effects? Will this medicine interact with medicines that I’m already taking?
The American Medical Student Association is actively campaigning for safer working conditions for medical interns and residents and The American Academy of Orthopaedic Surgeons launched the Sign Your Site Campaign to prevent wrong site surgery which includes three actions, a review of the operative procedure with the patient and operating room personnel prior to surgery, a review of the patient’s chart in the operating room prior to surgery, and writing your initials at the operative site… Sign Your Site!
We we are not safe yet! Medical misadventures will continue to occur. The obstacles remain formidable what with overcrowding, overworked staff and cost cutting. In the meantime, patients must be vigilant, ask questions and be their own advocate.