When a fitter makes a mistake due to his incompetence while fixing a car it is awful but he is risking the vehicle of a customer which costs money, but it does not bring any tragedy. When a teacher makes an error while teaching the student he is risky to prepare an ignorant engineer, who at least will have to realize his ignorance in his future career and correct the lack of knowledge by self-education. When a doctor commits a mistake, he is risking the utmost value, the health and the life of a person who entrusted his life to a doctor.
While analyzing the nature of the errors in medical care, it would be the easiest way to blame ignorant doctors only and explain the errors by the shortages of their education or by their carelessness. The problem seems to be much more severe and complicated than just the doctor’s ignorance and their negligence.
A patient entrusts his life to a doctor and sometimes the change of a medical specialist may lead to even worse complications. Like health care and the system that delivers it becomes more complex, the opportunities for errors abound.
Correcting this will require a concerted effort by the professionals, health care organizations, purchasers, consumers, regulators, and policy-makers1.
A patient has nobody to rely upon but the doctor that is why the doctor’s mistakes may be fatal for the patient.
The situation with the errors in medical care even in such developed country as the United States is threatening. The report of the National Academy of Sciences’ Institute of Medicine states that between 44,000 and 98,000 people die because of the mistakes of medical professionals. It is more than some victims of the highway accidents, breast cancer, and AIDS2.
The system providing health care becomes more complicated and some medical mistakes reached the alarming values, and that is why the whole system requires the comprehensive approach to reduce the number of medical errors.
The situation with errors in medical treatment became the Administration’s concern, and that is why it urged Congress to create a National Center for Patient Safety within the Department of Health and Human Services to set goals for avoiding medical mistakes, track progress in meeting them and to fund research on better ways to prevent such errors3.
The cost of medical errors nationwide is enormous; the cost of the single error is out of calculation because no one can calculate the cost of death or impairment for the patient caused by the medical error. Total national costs (lost income, lost household production, disability and health care costs) of preventable adverse events (medical errors resulting in injury) are estimated to be between $17 billion and $29 billion, of which health care costs represent over one-half.
The errors reported in the official documents are believed to be only the upper part of the iceberg that forms the problem. It would be wrong to blame the personalities only. “The problem is not bad people; the problem is that the system needs to be made safer.”5
People believe that the medical errors are restricted by the misuse of the drugs or by the surgical errors only. But the problem is much more complicated. There are many other types of medical errors which include:
- Diagnostic error, such as misdiagnosis leading to an incorrect choice of therapy, failure to use an indicated diagnostic test, misinterpretation of test results, and failure to act on abnormal results.
- Equipment failure, such as defibrillators with dead batteries or intravenous pumps whose valves are easily dislodged or bumped, causing increased doses of medication over too short a period.
Infections, such as nosocomial and post-surgical wound infections.
- Blood transfusion-related injuries, such as giving a patient the blood of the incorrect type.
- Misinterpretation of other medical orders, such as failing to give a patient a salt-free meal, as ordered by a physician6.
If the errors listed above are analyzed properly, it is not too much difficult to understand the reasons of such errors. Errors connected with the diagnostic problems occur mainly because of the “human factor,” improper professional training. At the same time, a doctor takes sole responsibility while making a diagnosis.
There are various types of misdiagnosis ranging from a wrong diagnosis to a partial misdiagnosis as to the wrong subtype, underlying condition, medication causes, related conditions, or complications. Conditions for which a person never seeks medical advice are also a common type of misdiagnosis7.
There are four main factors which participate in the process of diagnosing in particular and medical care in general. They are a patient, a doctor, a specialist and the tests (laboratory or pathology tests).
Misdiagnosis may occur because of any of above-indicated factor. The patient is a key person may influence the results of the diagnostics. First of all, it could happen because of both under awareness of the medical issues and over-awareness of them. In the first case, the patient fails to report the symptoms because of multiple factors ranging from embarrassment to carelessness to his health status. The solution of the problem could be the proper patient education on the role of the medical staff, the importance of reporting all symptoms. In the second case the patient under the influence of popular literature, other non-professional medical information may make self-diagnostics which is false and can not be true because of lack of professional knowledge of the patient. In this case, a patient may fail to perform prescribed tests or treatment relying upon his non-professional knowledge.
In some countries, there is a boom of the food additives which are advertised like panacea from all health troubles. They bring neither harm nor benefits, or if any benefits, they are very doubtful, but people sometimes take them as the medications from all diseases and what is worse they sincerely believe in them.
The misdiagnosis may occur due to the doctors’ mistakes. These mistakes can happen because there are more than 20,000 human diseases, and doctors only know the most common. It would be the easiest way to blame doctors in this case, but who could train a doctor who would know all existing diseases, identify them by appropriate symptoms and prescribe the proper treatment? There are no such doctors. That is why the best solution for such problems would be the conference of specialist doctors which should take place in certain cases which need to be defined. Such consultations should take place if any doubt occurs. Such measures may cause additional costs, but if they are introduced as an obligatory regulation on the exchange basis, these costs may be reduced. For example, doctors may re-examine the patients of their colleagues and vice versa.
The doctors’ mistakes may occur because of the doctors’ skill level. It is very important to distinguish inappropriate skill level from the incompetence or what is worse from ignorance.
The solution of the problem could be in re-certification of the doctors on the regular basis, regular examination of their knowledge by special commissions. Each case of medical mistake should be reported and become a subject of a thorough investigation by the specially appointed commission.
The cause of mistake may be the doctor’s subjective attitude towards a disease or a patient. All doctors are human beings, and sometimes it is difficult for them to go beyond their personal opinions in their justifications. In this case, doctors at least should have some doubts about their actions. A doctor may commit a mistake when he faces some atypical, and this should be an alert for him. He should not rely on his own experience in this case because the experience of a particular doctor may be erroneous.
As for some subjective attitude towards the patient, the doctor should immediately change it and treat the patient in a way it is required by the ethics of his profession. The doctor does not have any right for prejudice against the patient otherwise he needs to quit his professional activity. Any case of prejudiced attitude towards the patient should be investigated immediately, and certain discipline measures towards doctors should be taken.
One of the most dangerous mistakes of doctors is the medication errors. The National Coordinating Council for Medication Error Reporting and Prevention defines a medication error as “any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer…related to professional practice, healthcare products, procedures, and systems, including prescribing; order communication; product labeling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use.”9
The figures of injuries caused by medication errors are threatening. Every year, over 6,000 Americans die from workplace injuries. Medication errors alone, occurring either in or out of the hospital, are estimated to account for over 7,000 deaths annually.10
The medication errors if the errors due to the doctors’ incompetence are excluded may be technical errors and errors caused by the human factor. Technical errors are more or less connected with the human factor that is why it is a little bit difficult to make distinct distinguishing.
Communication errors are considered to be the technical errors. They occur when the order for medication is misinterpreted. Such errors take place when pharmacists misunderstand the order and prepare wrong medication. It could be avoided by the additional examination of the prescription by the trained staff. Pharmacists normally have specific general medical knowledge, and in case of any doubt, they need to contact the specialists who are competent enough to clarify the order. Most likely the problem may occur because of poor communication between practitioners and pharmacists. The way to resolve the problem is not difficult at all. The pharmacists should contact a practitioner in case of any doubt. If the medication causes harm for the patient such case should be examined and the responsibility should be shared between the doctor and the pharmacist.
The medication errors may occur because of the name confusion of both the patient and medication. This may happen both in hospitals and in the pharmacies. This fault is purely human factor fault and people responsible for such mistakes if they cause severe complications should be exposed to discipline measures up to prohibition to practice medical care. The actual reason for the name confusion is the carelessness of the medical personnel no matter if it takes place in the pharmacy or the hospital.
Labeling and packaging though are considered to be technical mistakes they depend on the accuracy of the medical staff. The process of labeling and packaging could be mechanized, computerized or anything else but the human factor can not be excluded completely. The best solution for such a problem could be formalizing the process of packaging and labeling. Strict instructions, described processes which must be followed to may reduce the number of mistakes due to wrong labeling. In the quality management of companies and enterprises, there is a splendid tool called Quality Manual which describes the processes and defines the actions of the management.
The procedure of prescription, preparation and using the medication in the hospitals may be somehow considered as the technological processes, and if the methods of business quality systems similar to ISO or any other are applied to such processes at least at technical procedures, some mistakes may be reduced considerably.
One of the most curious phenomena is that people learned how to manage industrial/business processes by the quality management systems, but they don’t even try to apply them to medical care. Of course, these systems cannot be applied in the way they exist in industry and business, but people at least may try to adapt them to medical care.
The problem of medical errors is a nationwide complicated problem and should be resolved on the national level. First of all, the mistakes should be reported, filed and analyzed. The special environment should be created to encourage the medical mistakes reporting. The technical issues like medication preparations, dozing, and delivery should be regulated by the strict regulations similar to those implemented in the business/industrial quality management systems.
To reduce mistakes connected with the human factor medical care system should be built presupposing multi-level control and multi-specialist decision taking when it comes to any doubt of a single specialist regarding the medication prescription, diagnosing and the strategy of medical treatment.
The patients should be educated properly regarding their role in medical care. The manufacturers of the drugs should take more active role in educating the practitioners on the medication prescription and use.
The moral factors of a profession of a doctor, his responsibility for the health of a patient should be propagandized. A doctor, unlike other people, does not have the right for mistake otherwise he will need to change the profession because the rate of the doctor’s mistake is too high and may become fatal for the patient.
Linda T. Kohn and her colleagues in the book “To Err Is Human: Building a Safer Health System” gives excellent recommendations how to improve the safety of the patient and avoid the medical errors. It is difficult to disagree with them that this activity should be comprehensive and performed on the national level as soon as the issue concerns the safety of the nation.
1. Linda T. Kohn, Janet M. Corrigan, and Molla S. Donaldson,
2. Eileen O’Connor
6. Medical Errors: The Scope of the Problem
7. Overview of Misdiagnosis
9. Melissa Conrad Stöppler, MD
10. Linda T. Kohn
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