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See also preventable medical errors Image File history File links Unbalanced_scales. ... Image File history File links Gnome-globe. ... As a general acceptance, a medical error occurs when a health-care provider chose an inappropriate method of care or the health provider chose the right solution of care but carried it out incorrectly. ...

In the United States medical error is estimated to result in 44,000 to 98,000 unnecessary deaths and 1,000,000 excess injuries each year.^[1][2] It is estimated that in a typical 100 to 300 bed hospital in the United States, excess costs of $1,000,000 to $3,000,000 attributable to prolonged stays and complications just due to medication errors occur yearly. medicines, see medication and pharmacology. ... The word error has different meanings in different domains. ...

Medical care is frequently compared adversely to aviation, in that, while many of the factors which lead to error are similar, aviation's error management protocols are much more effective.^[3] Aviation refers to flying using aircraft, machines designed by humans for atmospheric flight. ...

Epidemiology of medical error

Medical errors are associated with inexperienced clinicians, new procedures, extremes of age, complex care and urgent care.^[4] Poor communication, improper documentation, illegible handwriting, inadequate nurse-to-patient ratios, and similarly named medications are also known to contribute to the problem.

Approaches to error

Traditionally, errors are attributed to mistakes made by individuals who may be penalized for these mistakes. The usual approach to correct the errors is to create new rules with additional checking steps in the system, aiming to prevent further errors. As an example, an error of free flow IV administration of heparin is approached by teaching staff how to use the IV systems and to use special care in setting the IV pump. While overall errors become less likely, the checks add to workload and may in themselves be a cause of additional errors.

A newer model for improvement in medical care takes its origin from the work of W. Edwards Deming in a model of Total Quality Management. In this model, there is an attempt to identify the underlying system defect that allowed the opportunity for the error to occur. As an example, in such a system the error of free flow IV administration of Heparin is dealt with by not using IV heparin and substituting subcutaneous administration of heparin, obviating the entire problem. However, such an approach presupposes available research showing that subcutaneous heparin is as effective as IV. Thus, most systems use a combination of approaches to the problem. William Edwards Deming was an American statistician, college professor, author, lecturer, and consultant. ... Total Quality Management (TQM) is a management strategy aimed at embedding awareness of quality in all organizational processes. ...

The field of medicine that has taken the lead in systems approaches to safety is Anaesthesiology.^[5] Steps such as standardization of IV medications to 1 ml doses, national and international color coding standards, and development of improved airway support devices has made anesthesia care a model of systems improvement in care. Anesthesia (AE), also anaesthesia (BE), is the process of blocking the perception of pain and other sensations. ...

The profession of pharmacy has extensively studied the causes of errors in the prescribing, preparation, dispensing and administration of medications. As far back as the 1930’s, pharmacists worked with physicians to select from many options, the safest and most effective drugs available for use in hospitals ^[6]. The process is known as the Formulary System and the list of drugs is known as the Formulary. In the 1960’s, hospitals implemented unit dose packaging and unit dose drug distribution systems to reduce the risk of wrong drug and wrong dose errors in hospitalized patients^[7]; centralized sterile admixture services were shown to decrease the risks of contaminated and infected intravenous medications^[8]; pharmacy computers screened each patient’s medication list for drug-drug interactions^[9]; and, pharmacists provided drug information and clinical decision support directly to physicians to improve the safe and effective use of medications^[10]. Pharmacists are recognized experts in medication safety and have made many contributions that reduce error and improve patient care over the last 50 years.

A 2005 study by Wendy Levinson of the University of Toronto showed surgeons discussing medical errors used the word "error" or "mistake" in only 57 per cent of disclosure conversations and offered a verbal apology only 47 per cent of the time.^[11] The University of Toronto (U of T) is a coeducational public research university in Toronto, Ontario, Canada. ...

Examples of errors

1. Misdiagnosis
2. Giving the wrong drug or (wrong patient, wrong chemical, wrong dose, wrong time, wrong route)
3. Giving two or more drugs that interact unfavorably or cause poisonous metabolic byproducts
4. Wrong site surgery such as amputating the wrong limb

In general, a diagnosis (plural diagnoses) covers a broad spectrum, or spectra, of testing in some form of analysis; such tests based on some collective reasoning is called the method of diagnostics, leading then to the results of those tests by ideal (ethics) would then be considered a diagnosis, but... Oral medication A medication is any drug taken to cure or reduce the symptoms of an illness or ongoing medical condition. ... A few of the metabolic pathways in a cell. ... A cardiothoracic surgeon performs a mitral valve replacement at the Fitzsimons Army Medical Center. ...

Methods to improve safety and reduce error

Main article: Patient safety

1. patient's informed consent policy
2. patient's getting a second opinion from another independent practitioner with similar qualifications
3. voluntary reporting of errors (to obtain valid data for cause analysis)
4. root cause analysis
5. electronic devices (e-pill medication reminders [1]) to help patients maintain medication adherence
6. systems for ensuring review by experienced or specialist practitioners^[12]

Patient safety is a relatively recent initiative in medicine, emphasizing the reporting, analysis and prevention of medical error and adverse health care events. ... Informed consent is a legal condition whereby a person can be said to have given consent based upon an appreciation and understanding of the facts and implications of an action. ... Root cause analysis (RCA) is a class of problem solving methods aimed at identifying the root causes of problems or events. ...

See also

• Adverse effect (medicine)
• Biosafety
• Complication (medicine)
• Iatrogenesis
• Medical malpractice
• Preventable medical errors
• Swiss Cheese model of accident causation in human systems
• Wrong medication - medication errors
• Negligence
• Patient safety
• Total Quality Management

Adverse effect, in medicine, is an abnormal, harmful, undesired and/or unintended side-effect, although not necessarily unexpected, which is obtained as the result of a therapy or other medical intervention, such as drug/chemotherapy, physical therapy, surgery, medical procedure, use of a medical device, etc. ... Biosafety: prevention of large-scale loss of biological integrity, focusing both on ecology and human health. ... Complication, in medicine, is a unfavorable evolution of a disease, a health condition or a medical treatment. ... Ancient Greek painting in a vase, showing a physician (iatros) bleeding a patient. ... Medical malpractice is an act or omission by a health care provider which deviates from accepted standards of practice in the medical community and which causes injury to the patient. ... As a general acceptance, a medical error occurs when a health-care provider chose an inappropriate method of care or the health provider chose the right solution of care but carried it out incorrectly. ... In the Swiss Cheese model, individual weaknesses are modelled as holes in slices of swiss cheese, such as this Emmental. ... One of the major issues related to healthcare is the relatively high number of errors in medication that occur. ... Negligence is a legal concept usually used to achieve compensation for accidents and injuries. ... Patient safety is a relatively recent initiative in medicine, emphasizing the reporting, analysis and prevention of medical error and adverse health care events. ... Total Quality Management (TQM) is a management strategy aimed at embedding awareness of quality in all organizational processes. ...

References

1. ^ Institute of Medicine (2000). To Err Is Human: Building a Safer Health System (2000). The National Academies Press. Retrieved on 2006-06-20.
2. ^ Charatan, Fred (2000). Clinton acts to reduce medical mistakes. BMJ Publishing Group. Retrieved on 2006-03-17.
3. ^ Helmreich, Robert (2000). On error management: lessons from aviation. BMJ Publishing Group. Retrieved on 2006-03-17.
4. ^ Weingart, Saul; Ross Wilson, Robert Gibberd, Bernadette Harrison (2000). Epidemiology of medical error. BMJ Publishing Group. Retrieved on 2006-03-17.
5. ^ Gaba, David (2000). Anaesthesiology as a model for patient safety in health care. BMJ Publishing Group. Retrieved on 2006-03-17.
6. ^ Pease E. Minimum standards for a hospital pharmacy. Bull Am Coll Surg 1936;21:34-35
7. ^ Chapter IV.1 Medication Distribution Systems, Garrison TJ (au) in Handbook of Institutional Pharmacy Practice, Smith MC and Brown TR eds, Williams and Wilkins Co. 1979,
8. ^ Chapter IV.3 Developing Intravenous Admixture Systems, Woodward WA and Schwartau N (au) in Handbook of Institutional Pharmacy Practice, Smith MC and Brown TR eds, Williams and Wilkins Co. 1979,
9. ^ Chapter 53 The Patient Profile System, Powell MF (au) in Handbook of Institutional Pharmacy Practice, Smith MC and Brown TR eds, Williams and Wilkins Co. 1986,
10. ^ Chapter 31 Communicating Drug Information, Evens RP (au) in Handbook of Institutional Pharmacy Practice, Smith MC and Brown TR eds, Williams and Wilkins Co. 1986,
11. ^ Kelly, Karen (2005). Study explores how physicians communicate mistakes. University of Toronto. Retrieved on 2006-03-17.
12. ^ Espinosa, James; Thomas Nolan (2000). Reducing errors made by emergency physicians in interpreting radiographs: longitudinal study. BMJ Publishing Group. Retrieved on 2006-03-17.

For the Manfred Mann album, see 2006 (album). ... June 20 is the 171st day of the year (172nd in leap years) in the Gregorian Calendar, with 194 days remaining. ... For the Manfred Mann album, see 2006 (album). ... March 17 is the 76th day of the year in the Gregorian Calendar (77th in leap years). ... For the Manfred Mann album, see 2006 (album). ... March 17 is the 76th day of the year in the Gregorian Calendar (77th in leap years). ... For the Manfred Mann album, see 2006 (album). ... March 17 is the 76th day of the year in the Gregorian Calendar (77th in leap years). ... For the Manfred Mann album, see 2006 (album). ... March 17 is the 76th day of the year in the Gregorian Calendar (77th in leap years). ... For the Manfred Mann album, see 2006 (album). ... March 17 is the 76th day of the year in the Gregorian Calendar (77th in leap years). ... For the Manfred Mann album, see 2006 (album). ... March 17 is the 76th day of the year in the Gregorian Calendar (77th in leap years). ...

Book

• Banja, John Medical Errors and Medical Narcissism, 2005

• Porter, Michael E. and Olmsted Teisberg, Elizabeth Redefining Health Care: Creating Value-Based Competition on Results, 2006

External links

• Institute of Medicine's Healthcare Quality Initiative
• The Leapfrog Group Provides free ratings of quality and safety at local US hospitals.
• Institute for Healthcare Improvement
• AHRQ Patient Safety Network
• National Patient Safety Foundation
• Health Care Disclosure Project Project to improve quality through public reporting of physician and hospital performance.
• Hospital Compare A tool consumers can use to compare how well U.S. hospitals care for adult patients.
• Joint Commission Resources An organization dedicated to improving patient safety and quality of care.
• Joint Commission on Accreditation of Healthcare Organizations A private, not-for-profit organization and the nation's leader in continuously improving patient safety and health care quality.
• Wu AW. Medical error: the second victim. BMJ 2000; 320: 726-727
• Reason J. Human error: models and management. BMJ 2000; 320: 768-770
• "Why Doctors So Often Get It Wrong" by David Leonhardt, New York Times, Feb. 22, 2006
• Y. Bar-Yam, Making Things Work NECSI/Knowledge Press, 2005
• PRWEB on Medical Error
• Amalberti R, Auroy Y, Berwick D, et al. Five system barriers to achieve ultra safe health care. Ann Intern Med 2005;142:756-64
• Pittsburgh Regional Health Initiative, a leader in the application of Toyota-based quality engineering in health care