People expect medicines and medical devices to make them feel better and improve their health.
However, medicine and medical equipment, like any other product, are prone to manufacturing flaws, design flaws, warning flaws, and other issues that are not the user’s fault.
Furthermore, some medical devices and drugs may carry hidden dangers that are not obvious until many individuals use them.
Many hospitals in the United States have safety records that would be unacceptable in any other industry.
The figures are frightening:
- Every year, over 200,000 individuals die as a result of hospital errors, injuries, accidents, and infections.
- Every year, one out of every twenty-five patients develops an infection while in the hospital—an infection that could have been avoided.
- A Medicare patient has a one-in-four probability of suffering injury, harm, or death when admitted to a hospital.
- More than 1000 individuals will die today alone due to an avoidable healthcare error.
It’s crucial to remember that most hospital errors are avoidable. Hospitals must work daily to protect patients from errors, injuries, accidents, and infections.
The Scope of the Issue
In the early 1970s, studies to estimate the frequency of errors resulting in hospital injuries and deaths began.
According to a meta-analysis of such studies, the average yearly fatality rate from such errors in the first decade of the 2000s was over 250,000. That’s more than enough to make poor medical treatment the third leading cause of mortality in the United States, trailing only heart disease and cancer.
Because hospital medical records frequently fail to document incidences of iatrogenic injury, various ways to detect it have been developed.
The Institute for Health Care Improvement developed the Global Trigger approach, which scours medical records for tiny signals that a patient has suffered unforeseen harm.
A 2013 meta-analysis of Global Trigger research discovered ten times as many adverse events as standard record reviews, with as many as 440,000 deaths each year. Other studies that used on-the-scene observers discovered a comparable number of events.
However, hospitals are not the only places where healthcare is provided. Outside of hospitals, where the error profile is distinct, driven by diagnostic and pharmaceutical errors, there are far more patient contacts.
According to the scant data available, the number of deaths caused by an iatrogenic injury outside hospitals is roughly equivalent to the number within hospitals.
The Characteristics of Medical Errors
The reasons for injury range greatly, including:
- Scalpel slips
- Mistakes such as mixing up lab data
- Poor decision-making
- Insufficient training
- Avoidance of recognized safety practices
- Miscommunication
- Equipment malfunctions
It’s amazing how easily medical mistakes may happen.
A doctor in New Mexico accidentally sedated a 2-year-old child with an adult dose of morphine during a bronchoscopy to remove a sunflower seed that had gone down his airway instead of his esophagus, causing him to cease breathing and causing serious lasting brain damage.
A lab in New York State mislabeled a tissue sample, resulting in a double mastectomy for a lady who did not have breast cancer while cancer spread inside the woman who did. Surgeons still get left and right mixed up, and it’s not uncommon for patients to receive the incorrect drug or dose.
Anesthesiology has a unique success story. Anesthesiologists investigated the errors causing litigation and devised processes and instruments to help them work more safely.
Because of this study, the deaths caused by general anesthesia decreased from more than one in 5,000 patients in the 1950s to as few as one in 250,000 by 2000 — a 50-fold reduction.
Other specialties, however, have not found analogous avenues to advancement.
Sometimes the most obvious problems defy resolution. Healthcare personnel may not always sanitize their hands between patients, allowing infection to spread. Increasing hand hygiene compliance has proven to be a continuous difficulty for infection control professionals.
The current view is that organizational solutions to medical errors are more likely to be developed than expecting individual doctors to be aware of all relevant data at all relevant times and take all relevant actions.
Hospitals include numerous moving parts: various caregivers, layers of support workers, a wide range of patients, various gadgets and tools, an even greater range of medications, records, processes, protocols, treatment areas, and more.
Mistakes can occur if the correct components do not come together in the right place, at the right time, and in the right way.
According to the systems approach, the “system” that controls these interconnected pieces needs to be modified to make it more difficult for things to go wrong. This method is extremely effective in other areas, including manufacturing and commercial aviation.
This approach considers that humans will make mistakes and that the most effective way to improve patient safety is to make the system error-proof.
Consider an Illinois hospital that has committed to decreasing medication-related accidents and errors. It engaged a team of systems engineers to study the entire process throughout the hospital, identify error reasons, and recommend a comprehensive redesign (without having the luxury of computer-based order entry).
The team discovered that each unit inside the hospital had its own medicine ordering protocols, which added to the problem of physicians’ handwritten orders being frequently unreadable. Miscopying, omitting, or missing doctors’ orders resulted in several mishaps.
Nursing staff frequently interrupted pharmacists to discuss issues such as missing medications, causing them to lose concentration on the task at hand and resulting in more errors. The team’s goal was to cut errors in half, but their system overhaul cut errors by 90%.
Overcoming Obstacles to Solutions
Individual caregivers cannot find, plan, or implement improvements to the systems in which they work. However, both legal and informal malpractice liability and medical discipline focus on the clinician, while the organization and its administrators typically evade penalties.
Thus, accountability frequently attaches to individual providers who cannot make critical adjustments, while managers who can make necessary changes lack the appropriate incentives to do so.
Existing incentives push in the incorrect direction. Because iatrogenic injury necessitates greater medical care, errors generate more income for the organization; however, no hospital executive sees errors as a means of increasing revenue.
Meanwhile, system change necessitates the expenditure of funds, time, and new expertise. If management made such investments and successfully prevented harm, the organization’s income would fall.
What Should I Do if I See a Mistake in the Hospital?
If you are concerned, suspect that something is wrong, or see an error in a hospital, you should:
- Talk to someone immediately: The closer this person is to your direct care, the better. A smart place to start is with your bedside nurse. If no one you know is there, do not wait to report the occurrence. All healthcare team members, from physicians to cleaning staff, are there to make your care as safe as possible.
- Discuss the problem in a respectful yet forceful tone: No one wants to make a mistake, so notify the caregiver so they may resolve the issue as soon as possible. If this occurs, speak with a hospital professional who can investigate and fix the issue.
Make it clear that you expect to hear back about the problem and want something done to correct it. After reporting, you or a family member should follow up.
How Can a Lawyer Assist Me With a Medical Malpractice Lawsuit?
Accidents involving pharmaceutical medications and medical devices frequently occur when people least expect them to. You should consult a personal injury attorney if a medical device or medicine has harmed you. Your lawyer can assist you in obtaining compensation for your injuries.
