kin 3457 - medical errors

what is an adverse event?

unintended injury to patients caused by medical management:

• measurable disability

• prolonged hospital care

• or both

what is medical error?

preventable adverse event in health care

- inaccurate/ incomplete diagnosis or treatment of a disease, injury, syndrome behaviour, infection or other ailment

what is a near miss?

errors that occur that are detected before a patient is harmed

what is negligence?

when adverse event is caused by intentional or irresponsible practice

what is error of omission?

actions not taken

ex: missing a patient on rounds, not strapping patient into a wheelchair

what is error of commission?

wrong action taken

ex: giving medication to wrong patient, operating on wrong limb

what can medical errors be result of?

- unintended act

- use of the wrong plan

- failure of a planned action

which levels can medical errors occur at?

- individual level

- system level

how many people die prematurely due to medical error every year?

400,000

what are the system level approach designs? (ITPO)

- individual

- technological

- procedural

- organizational

what is an individual approach?

address the human factors to prevent the error from occurring in the first place

ex: training, continued education

what is technological approaches?

provides support to information processing that enhance precision and/or minimize errors

ex. blood vessel visualizer, arthroscopy, robot assist, positioning guides

what is a procedural approach?

address the processes involved in patient care that can result in error

ex: medication ordering errors (dose or frequency), limb verification before surgery, labelling

what are organizational approaches?

address the organizational structure to facilitate patient care and minimize risk of error

ex: scheduling, number of staff, shift length

what is the IPASS and how did it affect medical error?

Illness severity, patient summary, action list, situation awareness, synthesis by receiver

- medical error rate decreased by 23% and preventable adverse event rate decreased by 30%

why is an organizational approach important?

errors increase in fatigued circumstances

• intervention schedule signif. reduced serious medical, medication and diagnostic errors