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M
edical errors are common in the
United States, however, many are also
preventable. Here are 10 notes on
medical errors.
1. Since the 1999 Institutes of Medicine report
"To Err is Human," annual adverse events have
hit 100,000 to 400,000 per year, according to a
Philly.com article written by Maryanne McGuckin,
Dr.ScEd, FSHEA, president of McGuckin Methods
International and member of the World Health Or-
ganization's Global Patient Safety Challenge.
1
2. ere are 120 adverse events per 100,000 hospi-
tal admissions each year. ere are around 4,000
surgical near-misses or adverse events, including
wrong-site surgery.
1
3. Similarly, a 2015 Vox article stated that medi-
cal errors ranked third among the leading causes
of death in the United States. Around 2 percent
to 3 percent of the people who go into hospitals
receive severe harm as a result.
4. According to U.S. News & World Report, the
following are the most common preventable
medical errors:
2
• Medication errors
• Too many blood transfusions
• Too much oxygen for premature babies
• Healthcare-associated infections
• Infections from central lines
5. A 2015 study in Anesthesiology found that one
in 20 perioperative medication administrations
included a medication error and/or adverse drug
event.
3
A total of 277 operations were observed
with 3,671 medication administrations of which
193 involved a medication error and/or adverse
drug event. Of these, 79.3 percent were prevent-
able and 20.7 percent were nonpreventable.
6. Hospitals were the main site for sentinel events
from 2004 to 2015, with 6,248 events reported,
according to e Joint Commission.
4
Ambula-
tory care organizations were the site of 351 senti-
nel events in that decade. e Joint Commission
defines a sentinel event as "an unexpected occur-
rence involving death or serious physical or psy-
chological injury, or the risk thereof."
7. While checklists are oen used in healthcare
settings to try to prevent adverse patient events, a
2015 study in JAMA Surgery found that checklist-
based quality improvement initiatives may not be
effective at achieving that goal. Researchers exam-
ined Michigan Hospital Association's Keystone
Surgery effort, a checklist-based quality improve-
ment intervention implemented by many hos-
pitals in the state. Program implementation was
not associated with improved outcomes in the 14
hospitals participating in Keystone Surgery, ac-
cording to study results.
8. In June 2015, the National Patient Safety Foun-
dation released guidelines developed to help
healthcare organizations improve the way they
investigate medical errors, adverse events and
near misses. NPSF, with a grant from e Doctors
Company Foundation, convened a panel of ex-
perts and stakeholders to examine best practices
around root cause analyses and developed new
standardized guidelines.
9. e issue of medical errors is also clear on the
state-level. According to a Harvard School of
Public Health, around 25 percent of the people in
Massachusetts reported experiencing a medical
error within the past five years. e wrong test,
surgery or treatment was given to 38 percent of
the people who reported medical errors; 32 per-
cent reported getting the wrong medication.
10. Medical errors in Indiana skyrocketed in 2015,
making them comparable to those of Washington.
Hospitals and other healthcare facilities in Indiana
reported a total of 114 preventable adverse medi-
cal events in 2014. Washington had 483 reported
preventable adverse medical events in 2014. n
References:
1. Philly.com, "Medical errors remain all too com-
mon - and deadly."
2. US News & World Report. "5 Common Prevent-
able Medical Errors."
3. Anesthesiology. "Evaluation of Perioperative
Medication Errors and Adverse Drug Events."
4. e Joint Commission. "Summary Data of Sen-
tinel Events."
10 Things to Know About Medical Errors
By Anuja Vaidya
Longer Surgical Resident Hours Don't Hinder Patient Care, Study
Says
By Max Green
E
xtending hours for surgical residents doesn't nega-
tively affect patient care, according to a New England
Journal of Medicine study. In fact, longer hours may im-
prove patient recovery if surgical residents stay with patients
post-operation or are on hand to help stabilize them in criti-
cal situations, according to the authors.
Researchers analyzed data from 117 residency programs
across 151 hospitals and health systems and found those
using more flexible duty hours for residents yielded no
significant difference in residents' self-reported satisfaction,
overall well-being, quality of training or patient outcomes
for 10 metrics.
The conclusions of the new study, which were presented
at the Academic Surgical Congress on Tuesday, are a bit
counterintuitive. Longer clinical hours are often associated
with fatigue, burnout or slip-ups, and the issue has attracted
regulatory attention. The Accreditation Council for Graduate
Medical Education revised its policies around shift hours for
residents twice, first in 2003 and again in 2011. The 2003
revision mandated that residents work under 80 hours per
week, including restrictions for minimum amount of time
between shifts and caps on overnight shift length. The 2011
update decreased the acceptable shift length for residents
and increased the amount of time they are required to take
off between shifts.
However, the authors suggest the real cause of errors in
patient care occur during hand-offs, when a physician or
medical staffer updates the incoming clinicians about the
status of a patient.
"In surgery, this more frequent turnover may compromise
continuity of patient care, potentially jeopardize patient
safety and decrease the quality of resident education by
forcing residents to leave at critical times, such as in the
middle of an operation or while stabilizing a critically ill pa-
tient," Karl Bilimoria, MD, director of the Surgical Outcomes
and Quality Improvement Center at Northwestern University
Feinberg School of Medicine in Chicago and co-author of
the study, said in a statement.
Greater flexibility in surgical resident works hours can pre-
vent patient care disruptions without impacting outcomes or
surgical education, the authors concluded. n
Quality
