In 1999, the Institute of Medicine (IOM) released a landmark report, To Err is Human, estimating that at least 44,000, and as many as 98,000, patients die in hospitals each year as a result of preventable medical errors. The IOM is an independent nonprofit organization that provides unbiased information to the government and the public.
The IOM defined an error as “the failure of a planned action to be completed as intended (i.e., an error of execution) or the use of a wrong plan to achieve an aim (i.e., an error of planning).” These errors occurred at every phase of the medical system, including preventive care, diagnosis, treatment, and follow-up. The Report concluded the most likely place for these errors to occur were in the intensive care units, operating rooms, and emergency departments.
If the rate of preventable medical errors has continued at this pace since the 1999 IOM study, there have been another 500,000 to 1.1 million preventable deaths. It is noteworthy to mention that the IOM Report is limited to preventable medical errors in hospitals and does not include errors outside hospitals, such as in doctor’s offices, clinics, outpatient surgery centers, and nursing homes.
The following is a list of the types of medical errors that can occur:
1. Mistaken Patient Identity, which can lead to any of the following errors.
2. Medication Errors, such as a patient receiving the wrong drug or dosage 3. Surgical Error, such as amputating the wrong limb.
4. Diagnostic error, such as misdiagnosis leading to the wrong treatment, failure to use an indicated diagnostic test, misinterpretation of lab results or imaging studies, and failure to act on abnormal lab results or imaging studies.
5. 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, or fires in the operating room.
6. Infections, such as hospital acquired and post-surgical wound infections.
7. Blood transfusion-related injuries, such as a patient receiving an incorrect blood type.
8. Misinterpretation of other medical orders, such as failing to give a patient a salt-free meal, as ordered by a physician.
The Report also mentions that the physical injury a patient suffer is not the only loss suffered. Other losses include the increased cost of medical care to treat the physical injury, the victim’s lost income and household productivity, as well as physical disability.
The IOM states that the know-how exists to prevent many of these mistakes because the majority are the result of faulty systems and processes, not from individual recklessness. One example given is that hospital patient-care units are stocked with certain full-strength drugs that are toxic unless diluted, which has caused deadly mistakes. The thought is to make changes in the system which, in turn, will reduce the chances of individual errors. The IOM declares that health care is behind many other high-risk industries in its focus on basic safety, and it’s time to catch up.
Since this report was issued, some state governments have implemented medical error reporting systems. According to a Yale study, A National Survey of Medical Error Reporting Laws, Delaware does not have such a system. Not surprisingly, under reporting of medical errors has been a concern in states that have adopted such a regime. The Yale study lists serious reportable medical errors including: surgery on the wrong body part or on the wrong patient, the wrong surgical procedure performed, leaving surgical instruments or paraphernalia inside a surgical patient, and intraoperative and immediate postoperative death.
As an apparent consequence of the IOM Report, the Centers for Medicare & Medicaid Services (CMS) issued a press release that the federal government will no longer pay for treating certain preventable conditions in an attempt to encourage patient safety in hospitals. Unfortunately, since the IOM Report there has not been comprehensive, nationwide improvement. This may be the result of a lack of leadership, and physicians seeing change as a threat to their autonomy and authority.
Posted by Randall E. Robbins a Delaware injury lawyer with experience helping clients who have suffered hospital related injuries due to medical negligence.