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 Table of Contents  
Year : 2013  |  Volume : 1  |  Issue : 3  |  Page : 190-193

Medical errors in practice which medical fraternity must not forget: A critical look

1 Community Medicine, Muzaffarnagar Medical College and Hospital, Muzaffarnagar, Uttar Pradesh, India
2 Community Medicine, Subharti Medical College, Meerut, Uttar Pradesh, India

Date of Web Publication20-Mar-2014

Correspondence Address:
Sanjeev Davey
B-197, 3rd Floor, Prashant Vihar, Sector 14 Rohini, Delhi - 110 085
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2347-9019.129185

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Background: Medical errors are often described as human errors in healthcare. A medical error occurs when an inappropriate method of care or improper execution of an appropriate method of care happens. In fact, medical error is a preventable adverse effect in medical sciences practice, which is evident and harmful to the patient. Aims: To elucidate areas of medical errors; so as to understand, where medical fraternity has to become careful in medical practice via review of literature. Settings and Design: All kinds of study designs and examples from both developed as well as developing countries on medical errors were taken. Statistical analysis used: Review manager software was used to identify studies without any statistical test. Materials and Methods: A review of literature of last 10 years up to 20 th Nov 2013 was done in all forms including e-journals on key search word: "Medical errors in practice" with inclusion criteria of impact of medical errors globally on patients from all kinds of study designs from developed or developing world excluding thesis or dissertation data. Results and Conclusion: The umbrella of medical error includes wide areas such as an inaccurate or incomplete diagnosis or treatment of a disease, injury, syndrome, behavior, infection, etc., The usual approach to correct such errors is; to create new rules with additional checklists in clinical side and following newer models for improvement in medical care such as total quality management, which can identify areas for preventing medical errors and this can be further researched in future studies.

Keywords: Clinical practice, medical errors, medical fraternity

How to cite this article:
Davey S, Davey A. Medical errors in practice which medical fraternity must not forget: A critical look. Int J Health Syst Disaster Manage 2013;1:190-3

How to cite this URL:
Davey S, Davey A. Medical errors in practice which medical fraternity must not forget: A critical look. Int J Health Syst Disaster Manage [serial online] 2013 [cited 2021 May 15];1:190-3. Available from: https://www.ijhsdm.org/text.asp?2013/1/3/190/129185

  Background Top

Medical errors are emerging as a serious public health problem globally; impinging a threat to patient safety, but only few studies focus on their actual measurement. [1] Medical errors affect one in 10 patients worldwide and approximately 1.3 million people annually in the United States suffer from "medication errors". Medical errors are now considered as the third leading cause of death in America after heart disease (first) and cancer (second). [2] Preventing medical errors can be a cost effective approach by lowering healthcare costs, reducing doctors' insurance premiums, and protecting the health of the patients.

Medical error definitions are subject to debate and they range from minor to major; as their causality is often poorly known. [3],[4] A medical error is considered a preventable adverse effect of care, either evident or harmful to the patient such as an inaccurate or incomplete diagnosis or treatment of a disease, injury, syndrome, behavior, infection, or other ailment. 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, health care products, procedures, and systems, including prescribing; order communication; product labeling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use. There are basically two types of medical errors: (a) Cognitive errors such as incorrect diagnosis or b) choosing the wrong medication, more likely to have been preventable and more likely to result in permanent disability than technical errors. Medical errors are often described as human errors in healthcare. [5]

A recent study in Journal of Patient Safety (Allen, 2013); has elucidated the fact that; between 210,000 and 440,000 patients each year, who go to the hospital for care suffer some type of preventable harm that contributes to their death. [2] Another recent study, published in the International Journal of Clinical Pharmacy, involving Aston University (UK), South Essex Partnership University NHS Foundation Trust (SEPT), and the University of East Anglia (UK) found that medication errors were common on admission to mental health services as medication errors occurred in 56.2% of patients admitted to the assessment for 4 months in year 2012. [6]

The arena of medical errors is wide, as found from many examples from literature. In study on Breast Imaging Reporting and Data System (BIRADS) Mammography classification it was observed that; there is a wide variability in practice in the application of the BIRADS terminology and this study found that this lead to classification errors (Boyer et al., 2013). [7] Pediatric prescribing errors are also very prevalent and most of them are made by junior doctors; however, detecting errors in order to demonstrate actual error rates are very difficult to show, as noted in study at Royal Manchester Children's Hospital (RMCH) by Davis et al., (2013). [8] Issues of accurately defining and modeling competence in medication dosage calculation problem-solving can be a way to measuring competence and diagnosing errors as found in their study by Weeks et al., (2013). [9] With this problem in mind, the authors, therefore critically searched the impact of medical errors on patients from both developed as well as developing world by reviewing the literature.


To elucidate areas of medical errors; so as to understand, where medical fraternity has to become careful in medical practice via review of literature.

Settings and Design

All kinds of study designs and examples from both developed as well as developing countries on impact of medical errors on patients were taken.

Statistical analysis used

Review manager software was used to identify studies for review of literature, but no other statistical tests was used.

  Material and Methods Top

Search strategy

A review of literature of last 10 years up to 20 th November 2013 was done in all forms including e-journals on key search word: "Medical errors in practice".

Inclusion criteria

All kinds of study designs; including books, conferences data, internet information from developed and developing world, and elucidating impact of medical errors globally on patients were considered.

Exclusion criteria

Thesis/dissertation unpublished data was excluded while considering studies from literature.

  Results and Conclusions Top

Global trigger tool: A guide for medical errors management for clinicians

Medical errors can occur in the hospital, at physician's office, at the pharmacy, or at home. Elderly people are often at greatest risk for medication errors because they often take multiple prescription medications apart from other age groups, who are also vulnerable. Four recent studies on preventable harm suffered by patients known as "adverse events" as found in the medical vernacular 2013 used a screening method called the Global Trigger Tool, which guided reviewers through medical records, searching for signs of infection, injury, or error as found in literature (Mac Donald, 2013). [10] The tool provides instructions and forms for collecting the data need to track three measures: a) Adverse events per 1,000 patient days, b) adverse events per 100 admissions, and c) percent of admissions with an adverse event.

Global medical error scenario

In study of Bowser (2011) on 795 patients at three teaching hospitals, it came out that 354 of the patients had experienced medical mistakes, and 90% of all hospital mistakes went unreported and 30% of US adults and 22% of Canadians said they could make same-day doctor's appointments, compared with 55% in Germany. [11]

Spectrum of medical errors: Developed countries still bearing the most brunt

Preventable medical mistakes in the US currently account for one-sixth of all annual deaths. According to the most recent research into the cost of medical mistakes in terms of lives lost, 210,000 Americans are killed by preventable hospital errors each year. [12] When deaths related to diagnostic errors, errors of omission, and failure to follow guidelines are included; an estimated 440,000 preventable hospital deaths occurred each year. Burnout is also getting more common among physicians as a cause of medical error. Physicians in emergencies are at the greatest risk and a substantial portion of doctors in US also suffer from burnout on the job, according to a study published in the Archives of Internal Medicine (2012).[13]

Labeling of medical errors

Misdiagnosis is the main type of medical error in outpatient department of hospitals. A medical error occurs when a healthcare provider chooses an inappropriate method of care and or improperly executes an appropriate method of care. In an Institute of Medicine (IOM) report (2000) in US, it was noted that medical errors are estimated to result in about between 44,000 and 98,000 preventable deaths and 1,000,000 excess injuries each year in US hospitals. [14],[15],[16] Although some researchers doubt the accuracy of IOM study, which criticizes their statistical handling of measurement errors in their report, [17] a significant subjectivity in determining which deaths were "avoidable" or due to medical error, and an erroneous assumption that 100% of patients would have survived if optimal care had been provided has questioned such figures. [18] In an another study by the Journal of the American Medical Association (2001), they estimated that for roughly every 10,000 patients admitted to the subject hospitals, one patient died who would have lived for 3 months or more in good cognitive health had the "optimal" care been provided to them. [4]

In 2006 a follow-up study to the IOM study, found that medication errors are among the most common medical mistakes, harming at least 1.5 million people every year. According to this study; 400,000 preventable drug-related injuries occur each year in hospitals; 800,000 in long-term care settings; and roughly 530,000 among Medicare recipients in outpatient clinics. This report stated that these are likely to be conservative estimates. [18] According to an Agency for Healthcare Research and Quality report (a decade back) found that, nearly 7,000 people were estimated to die each year from medication errors, about 16% more deaths than the number attributable to work-related injuries (6,000 deaths), and one in five Americans (22%) report that they or a family member have experienced a medical error of some kind. [19]

Etiology of medical errors

Human errors are responsible for nearly 80% of adverse events which occur in complex healthcare systems. Medical errors commonly happen due to inexperienced physicians and nurses, new procedures, extremes of age, and complex or urgent care. [20] Poor communication, improper documentation, illegible handwriting, inadequate nurse-to-patient ratios, and similar named medications are commonly known factors in this problem. Patient actions can also contribute significantly to medical errors. The vast majority of medical errors also result from faulty systems and poorly designed processes versus poor practices or incompetent practitioners and many other factors such as: (a) Healthcare complexity; (b) system and process design; (c) competency, education, and training; and (d) human factors and ergonomics. [21] Errors can include misdiagnosis or delayed diagnosis, administration of the wrong drug to the wrong patient or in the wrong way, giving multiple drugs that interact negatively, surgery on an incorrect site, failure to remove all surgical instruments, failure to take the correct blood type into account, or incorrect record keeping.

Examples: Shocking medical errors!!!

List of key shocking mistakes, which a medical fraternity must avoid are given in [Table 1]. [22],[23],[24],[25],[26],[27],[28],[29]
Table 1: Key shocking medical errors which must be avoided

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Concept of swiss cheese model

Some doctors recognize that adverse outcomes from errors usually do not happen because of isolated errors and actually reflect system problems. This concept is often referred to as the Swiss Cheese Model. This is the concept that there are layers of protection for clinicians and patient to prevent mistakes from occurring. Therefore, even if a doctor or nurse makes a small error, for example, incorrect dose of drug written on a drug chart by doctor this is picked up before it actually affects patient care by the pharmacist who can check the drug chart and rectifies the error. [22],[23],[24],[25],[26],[27],[28],[29]

  Efforts to be taken further to prevent medical errors Top

Adverse events following immunization needs reduction by proper training

It has come out from study that healthcare provider spontaneous reporting of suspected AEFI is critical in monitoring vaccine safety and initiatives to improve education, such as increased training to healthcare providers, medical professionals, are required in both undergraduate curricula and ongoing, professional development to reduce errors in immunization, as found in study by Parrella et al., (2013). [30]

Diagnostic errors management; research needs to be expanded

This area remains an under emphasized and understudied area in patient safety research. Research is needed to study enhanced patient involvement in diagnosis, improving diagnosis through the use of electronic tools and identification and reduction of specific diagnostic process pitfalls, which was noted in study by Zwaan et al., (2013). [31]

Three approaches in this area to solve diagnostic error problem are: (1) Use 'trigger tools' to identify from electronic health records cases; (2) use standardized patients to study the rate of error in practice; and (3) encourage both patients and physicians to voluntarily report errors they encounter and this was suggested in study by Graber (2013). [32]

World health organization: Surgical safety checklist to be followed

This is one of the effective way of preventing such errors. In practice, surgical errors involving the wrong patient or wrong body site are preventable and final preoperative checks must be applied methodically and systematically by asking the patient to confirm his/her identity and the intended site of the operation. Healthcare staff must be aware of all these measures by proper training as advocated by WHO (2008). [33]

  Conclusion Top

Humans often make errors; so errors are also common in medicine, killing tens of thousands, but we need to act more on errors. Policies of naming, blaming, and shaming have no remedial value. What is required to avoid these errors by following safety measures such as (a) informed consent; (b) the availability of a second practitioner's opinion, (c) voluntary reporting of errors, (d) root cause analysis, (d) reminders to improve patient medication adherence, (e) hospital accreditation, and f) systems to ensure review by experienced clinicians and these areas needs further systematic review or meta-analytic studies on improving patients safety.

  References Top

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2.Allen M.[PROPUBLICA]. How many die from medical mistakes In U.S. Hospitals? [Internet c2013]. Available from: logs/health/2013 /09/20/224507654/how-many-die-from-medical-mistakes-in-u-s-hospitals [Last updated 2013 Sep 20, Last cited 2013 Nov 25].  Back to cited text no. 2
3.Timothy P, Hofer MD. What is an error? Effective clinical practice (American College of Physicians); 2000.  Back to cited text no. 3
4.Rodney A, Hayward MD. "Estimating hospital deaths due to medical errors: Preventability is in the eye of the reviewer". JAMA 2001;286:415-20.  Back to cited text no. 4
5.Howard J. "Malpractice lawsuits shed light on ailing outpatient system". My Advocates. Available from: http://myadvocatesblog.com/malpractice/malpractice-lawsuits-shed-light-on-ailing-outpatient-system [Last updated 2011 Jun 28; Last cited 2011 Jun 28].  Back to cited text no. 5
6.Medication Errors Common on Admission to Mental Health Units. [Internet c 2013]. Available from: http://english.farsnews.com/newstext.aspx?nn=139208270002 [Last Updated 2013 Nov 18; Last cited2013 Nov 18].  Back to cited text no. 6
7.Boyer B, Canale S, Arfi-Rouche J, Monzani Q, Khaled W, Balleyguier C. Variability and errors when applying the BIRADS mammography classification. Eur J Radiol 2013;82:388-97.  Back to cited text no. 7
8.Davis T, Thoong H, Kelsey A, Makin G. Categorising pediatric prescribing errors by junior doctors through prescribing competency assessment: Does assessment reflect actual practice? Eur J Clin Pharmacol 2013;69:1163-6.  Back to cited text no. 8
9.Weeks KW, Hutton BM, Young S, Coben D, Clochesy JM, Pontin D. Safety in numbers 2: Competency modeling and diagnostic error assessment in medication dosage calculation problem-solving. Nurse Educ Pract 2013;13:e23-32.  Back to cited text no. 9
10.Mac Donald I. Hospital medical errors now the third leading cause of death in the U.S. [New study highlights the fact that estimates in ′To Err is Human′ report were low]. [Internet c2013]. Available from: http://www.fiercehealthcare.com/story/hospital-medical-errors-third-leading-cause-death-dispute-to-err-is-human-report/2013-09-20#ixzz2lHmU0j7f [Last updated 2013 Sep 20, Last cited 2013 Sep 20].  Back to cited text no. 10
11.Medical Errors in the U.S. vs. Other Countries. [Internet c2013]. Available from: http://www.truthfulpolitics.com/http:/truthfulpolitics.com/comments/medical-errors-in-the-u-s-vs-other-countries/[Last updated 2011 Apr 17; Last cited 2013 Nov 22].  Back to cited text no. 11
12.James JT. A new, evidence-based estimate of patient harms associated with hospital care. J Patient Saf 2013;9:122-8.  Back to cited text no. 12
13.Shanafelt TD, Boone S, Tan L, Dyrbye LN, Sotile W, Satele D, et al. Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Arch Intern Med 2012;172:1377-85.  Back to cited text no. 13
14.Institute of Medicine Report. "To err is human: Building a safer health system". The National Academies Press; 2000. p. 1-311.  Back to cited text no. 14
15.Charatan F. "Clinton acts to reduce medical mistakes". BMJ 2000;320:597.  Back to cited text no. 15
16.Weingart SN, Wilson RM, Gibberd RW, Harrison B. "Epidemiology of medical error". BMJ 2000;320:774-7.  Back to cited text no. 16
17.Zhang J, Patel VL, Johnson TR. "Medical error: Is the solution medical or cognitive?" J Amn Med Inform Assoc 2008;6 (Supp1):75-7.  Back to cited text no. 17
18."Medication Errors Injure 1.5 Million People and Cost Billions of Dollars Annually". The National Academy of Science. 2006. [Internet c2013]. Available from: http://www8.nationalacademies.org/onpinews/newsitem.aspx?RecordID=11623 [Last updated 2013 Jan 13; Last cited 2013 Jan 13].  Back to cited text no. 18
19.Agency for Healthcare Research and Quality [Annual Report-The Commonwealth Fund] [National Health care Disparities Report]. 2002:1-227. [Internet c2013]. Available from: http://www.hablamosjuntos.org/resources/pdf/nhdr03.pdf [Last updated 2013 Nov 25; Last cited 2013 Nov 25].  Back to cited text no. 19
20.Weingart S, Wilson C, Marley BK. "Epidemiology of medical error". BMJ Publishing Group 2000; [Internet c2013]. Available from: http://bmj.bmjjournals.com/cgi/content/full/320/7237/774 [Last updated 2013 Nov 19; Last Cited 2013 Nov 19].  Back to cited text no. 20
21.Palmieri PA, DeLucia PR, Ott TE, Peterson LT, Green A. "The anatomy and physiology of error in adverse healthcare events". Adv Health Care Manag 2008;7:33-68.  Back to cited text no. 21
22.Hayward RA, Heisler M, Adams J, Dudley RA, Hofer TP. "Overestimating outcome rates: Statistical estimation when reliability is suboptimal". Health Serv Res 2007;42:1718-38.  Back to cited text no. 22
23.Hilfiker D. "Facing our mistakes". N Engl J Med 1984;310:118-22.  Back to cited text no. 23
24.Christensen JF, Levinson W, Dunn PM. "The heart of darkness: The impact of perceived mistakes on physicians". J Gen Intern Med 1992;7:424-31.  Back to cited text no. 24
25.Wu AW. "Medical error: The second victim. The doctor who makes the mistake needs help too". BMJ 2000;320:726-7.  Back to cited text no. 25
26.Waterman AD, Garbutt J, Hazel E, Dunagan WC, Levinson W, Fraser VJ, et al. "The Emotional Impact of Medical Errors on Practicing Physicians in the United States and Canada". Joint Commission J Qual Patient Saf 2007;33:467-76.  Back to cited text no. 26
27.Wu AW, Folkman S, McPhee SJ, Lo B. "Do house officers learn from their mistakes?". JAMA 1991;265:2089-94.  Back to cited text no. 27
28.Dean B, Barber N, Schachter M. "What is a prescribing error?". Qual Saf Health Care 2000;9:232‐7.  Back to cited text no. 28
29.Romero‐Perez R, Hildick‐Smith P. "Minimising prescribing errors in paediatrics‐ Clinical audit". Scot Univ Med J 2012;1:1-9.  Back to cited text no. 29
30.Parrella A, Braunack-Mayer A, Gold M, Marshall H, Baghurst P. Healthcare providers′ knowledge, experience and challenges of reporting adverse events following immunisation: A qualitative study. BMC Health Serv Res 2013;13:313.  Back to cited text no. 30
31.Zwaan L, Schiff GD, Singh H. Advancing the research agenda for diagnostic error reduction. BMJ Qual Saf 2013;22 Suppl 2:ii52-7.  Back to cited text no. 31
32.Graber ML. The incidence of diagnostic error in medicine. BMJ Qual Saf 2013;22 Suppl 2:ii21-7.  Back to cited text no. 32
33.World Alliance for Patient Safety. WHO surgical safety checklist and implementation manual. 2008;1. [Internet c2013]. Available from: http://www.who.int/patientsafety/safesurgery/ss_checklist/en/[Last updated 2008; Last cited 2013 Nov 25].  Back to cited text no. 33


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