Medical errors are ubiquitous and the costs (human and financial) are substantial. The top priority must be to redesign systems geared to prevent, detect and minimise effects of undesirable combinations of design, performance, and circumstance.

1. Special Feature
Dealing with Medical Errors
By : Dr. AK Khandelwal
Newspaper and television stories of catastrophic injuries occurring at the hands of
clinicians bring to highlight the problem of medical errors, but they provide little insight
into its nature or magnitude. In reality, these horrific cases that make the headlines are
just the tip of the iceberg. Medical errors are ubiquitous and their subsequent costs
(human and financial) are substantial.
Medical errors are a serious threat to patient safety in both hospitals and in the
community. Greater public awareness of clinical error combined with rapidly increasing
litigation and insurance costs have created a pressing need to implement risk
management in hospitals to improve patient safety.
Magnitude of problem
Medical error is the third most frequent cause of death in Britain after cancer and heart
disease and kills four times more people than any other kind of accidents.
Around 850,000 medical errors occur per year resulting in up to 40,000 unintended
patient deaths plus other harm in UK. The annual costs of "loss" is estimated to be
around 20% of budget to NHS organisations, UK.
Patients injured as a result of a medical error spend longer time in hospital and have
higher hospital costs. E.g. the length of stay increased by 1.9 to 2.2 days as a result of
adverse drug events in Utah and Harvard studies.
Brennan et al, reviewed the medical charts of 30,121 patients admitted to 51 acute care
hospitals and found that 69% of injuries were caused by errors. The Harvard study of
medical practice and a study of the quality of Australian healthcare, have found that

2. medical errors occur in 4-17 % of admissions and 30-51 % of these adverse events
were considered to be preventable and represent suboptimal care.
A report from the Institute of Medicine, USA, states that around 1,00,000 patients a year
die from preventable errors in hospitals in America. Donchin et al have reported that 1.7
errors per patient per bed occurred in a medical-surgical intensive care unit, by an
observational study at university hospital in Israel
What are medical errors?
Error: Failure of a planned action to be completed as intended (error of execution) or
use of a wrong plan to achieve an aim (error of planning); the accumulation of errors
results in accidents.
Active error: An error that occurs at the level of the frontline operator and whose
effects are felt almost immediately.
Latent error: Errors in the design, organisation, training, or maintenance that lead to
operator errors and whose effects typically lie dormant in the system for lengthy periods
of time.
Mechanism of errors
Active failures
Active failures are unsafe acts or omissions committed by those whose actions can
have immediate adverse consequences. The term active failures includes:
 Action slips or failures, such as picking up the wrong syringe
 Cognitive failures, such as memory lapses and mistakes through ignorance or
misreading a situation
 "Violations"deviations from safe operating practices, procedures, or standards.
Latent failures
Latent failures stem from fallible decisions, often taken by people not directly involved in
the workplace. In medicine, latent failures would be primarily the responsibility of
management and of senior clinicians at those times when they are taking decisions on
the organisation of their unit.
Latent failures provide the conditions in which unsafe acts occur; these work conditions
include:
 Heavy workloads
 Inadequate knowledge or experience
 Inadequate supervision
 A stressful environment
 Rapid change within an organisation
 Incompatible goals (for example, conflict between finance and clinical need)

3.  Inadequate systems of communication
 Inadequate maintenance of equipment and buildings
Barrier/Defence
In industries, and to a lesser extent in medicine, defences exist to guard against human
error and aid recovery from potential problems. In other industries, this might be a
failsafe device to shut down a reactor, in medicine the warning sound of a monitor
alerting an anaesthetist to falling blood pressure
Contributing factors
 Human failure: 46%
 Technical failure: 27%
 Organisational failures: 27%
Although we cannot change the aspects of human cognition that make us to err, we can
design systems that reduce error and make them safer for patients, and in turn will even
reduce errors due to gaps in human cognition
Medical errors can occur anywhere in the health care system, at hospitals or at patients’
homes. Errors can involve: medicines, surgery, diagnosis, equipment, lab reports, etc.
They can happen during even the most routine tasks, such as when a hospital patient
on a salt-free diet is given a high-salt meal. Errors also happen when doctors and their
patients have problems communicating.
Medical practitioners rely heavily on their administrative support staff for the smooth
running of their practice. In many practices, systems have developed by evolution rather
than design. Some work perfectly well but others may have inherent faults that are only
exposed when a problem occurs. Medical errors frequently result from interactions
between the host (patient), the environment (healthcare system), and the vector (often
the healthcare workers) of transmission. The Institute of Medicine report suggests that
environmental (healthcare system) factors may be the most important contributors to
medical error causation.
Development of Standard Operating Procedures (SOP's) for each function/area in the
hospital and induction training will prevent errors to a great extent.
Approaches to reduce medical errors
Step 1: Identifying risks
Practitioners examine the processes within their work and identify the key operational
risks, e.g., systems for repeat prescriptions, handling of test results, checking
instruments before and after surgery, receipt of telephone messages, and so on.

4. Step 2: Determining the cause
Practitioners then identify the sort of situations that could cause a breakdown in care.
For example, the absence of a system ensuring that the test results are seen and acted
upon before being filed.
Step 3: Considering the consequences
The consequences for the practice of each risk are then assessed. These are likely to
include injury/harm to patients or staff; death and damage to reputation.
Step 4: Assessing the likelihood of an adverse incident
Then the practitioners should take a view about, how likely it is that the practice will be
exposed to the risk
Step 5: Determining the risk
Once the consequences and likelihood of system failure in each of the areas identified
has been assessed, it is then possible to rate the risks in order of significance.
Obviously, the highest rating would be given to system failures with the worst
consequences and the greatest likelihood of occurring.
Step 6: Identifying and reviewing controls
Having identified and assessed the risks, practitioners review the controls that are
already in place. Are they adequate? How can they be improved? Do new controls need
to be introduced?
Step 7 : Action plan
The practice now understands where risks lie and the controls needed for managing
them. A clear action plan for improvement can now be drawn up for introducing new and
better controls/systems for managing risk. e.g., development of standard operating
procedures.
Analysis of medical error
Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) mandated
the use of Root Cause Analysis in the investigation of sentinel events in accredited
hospitals. Root Cause Analysis provide a structured and process-focused framework
with which to approach sentinel event analysis. Systems and organizational issues can
be identified and addressed, and active errors acknowledged..
Systems factors and safety
Strategies for the design of safe systems of care should focus on:
 Preventing errors
 Making errors visible –Detection
 Mitigating the effects of error
Tactics to reduce errors

5.  Reducing complexity
 Optimise information processing
 Automate wisely
 Use constraints
 Mitigate the unwanted side effects of change
Deploy these to support any of the three strategic components of error prevention,
detection, and mitigation. Review and renew them based on the organisational
performance feedback.
Redesign system
Errors made by an individual often reflect system-wide problems. The correct response
is to redesign systems so that errors are acknowledged, detected, intercepted, and
mitigated. Trying harder will not work, changing systems of care will. Systems should be
designed to catch error as early as possible
Conclusion
Healthcare institutions of today are complex matrix organisations. Errors are bound to
occur in any complex human endeavour, and healthcare is no exception. Medical errors
are ubiquitous and the costs (human and financial) are substantial. The top priority must
be to redesign systems geared to prevent, detect and minimise effects of undesirable
combinations of design, performance, and circumstance.
Safety improvement through system monitoring and feedback, and system and process
redesign from aviation and nuclear power industries hold many lessons for
healthcare. Healthcare institutions with patient safety as high priority should have a
blame-free, non-punitive system for reporting errors in medical care to peer-review
protected committees that are empowered to institute changes for system-wide
improvements to prevent future errors.
The author is the Medical Director at AnandaLoke Hospital &
Neuroscieneces Centre