Medical error, adverse event & near misses

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Medical Error, Adverse Event




And Near Misses





MADAM JULIE JAMES ABDULLAH

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Learning Outcome
















1 2 3











Differentiate Explain causes of Explain mechanism


Medical error, Medical error, to avoid medical


adverse event and adverse event, near errors

near misses misses and its


consequences

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DEFINITION

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i. Medical Error










Inevitable in the practice of medicine


• medicine is not an absolute science,
medicine is only an art (a skill)


• medicine inherent uncertainty

(uncontrollable, unpredictable)


• mistakes (an act or judgement that is

misguided or wrong) or oversight (an
unintentional failure to notice or do

something)

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i. Medical Error










• Represent a serious public health problem and pose a threat to patient safety

• Can occur anywhere in the healthcare system: in hospitals, clinics, surgical unit, drs’ offices,

nursing homes, pharmacies, and patients’ homes

• Can involve medicines, surgery, diagnosis, equipment, or lab reports












Many of these errors are the result of negligence on the part of doctors, nurses

and other healthcare professional who have a legal and professional duty to

provide their patients with an acceptable standard of medical care

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ii. Adverse Event










An adverse event is an incident that results in harm to the patient.





Adverse events commonly experienced in hospitals by patients over 70 include falls, medication errors,
malnutrition, incontinence, and hospital-acquired pressure injuries and infections.













“an injury resulting from medical treatment, as opposed to the underlying

disease process, that prolonged a patient’s hospitalization, caused

disability at the time of discharge, or both”

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iii. Near Misses










An event or situation that could have resulted in an
adverse event but did not (occur) either by chance

or through timely intervention.





An error that has the potential to cause an adverse
event (patient harm) but fails to do so because of

chance or because it is intercepted





“An error caught before reaching the patient”

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Causes Of Medical Error, Adverse Event, Near Misses And Its

Consequences.








i. Factors Contributing To Medical Errors

ii. Medical Errors consequences

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i. Factors Contributing To Medical Errors










1. Poor leadership in patients care

2. Provider/system factors


3. Inadequate knowledge & skill


4. Reluctant to admit error

5. Environmental / long working hours


6. System weaknesses


7. Patient factors

8. Language barrier


9. Elderly patient


10. Paediatric Patients

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Poor Leadership In Patients’ Care










Risky behaviours often emerge because of system-based problems in healthcare organizations.
Common at-risk behaviours include:





1. Engaging in “grab and go” with a medication without fully reading the label before it is dispensed,

administered or restocked


2. Intimidation or reluctance to ask for help or clarification

3. Failure to educate patients


4. Using medications without complete knowledge of the medication


5. Failure to double check high-alert medications before dispensing or administering

6. Not communicating important information such as patient allergies, diagnosis/co-morbid

conditions, weight

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Provider / System Factors










Provider factors included

• incomplete care


• defined as care missing one or more components of guideline-concordant care


• lack of knowledge, skill, or competence; lack of patient monitoring

• lack of trainee supervision; delay in care; lack of appropriate discharge planning


• delay in seeking needed consultation

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Inadequate Knowledge & Skill










Inexperience





• Administer a treatment for the very
first time without appropriate

preparation and supervision by
experienced staff.

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Reluctant To Admit Error










Why is it important to immediately admit our
mistakes in medicine?





If you admit a mistake and then try to rectify it, it is

much better for patient care.

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Environmental / Long Working Hours










The environment

• healthcare workers practice can also contribute to medical errors. Studies show that healthcare

workers were:





➢ Almost 3 times more likely to report a more hectic working environment in the 30 minutes before

the error compared to the rest of the error shift

➢ Nearly 2 times as likely to report a more hectic working environment when comparing the error

shift to the prior shift

➢ Four times more likely to report a more hectic working environment when comparing the 30

minutes before the error to the prior shift worked

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Environmental / Long Working Hours










Sleep deprivation

• Affect executive-level function and mood and also increase irritability, which can negatively affect

team functioning in healthcare settings and lead to burnout.





• It can also be related to staffing issues if workers are asked or required to work overtime or

additional shifts and simply are unable to obtain enough sleep.

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Environmental / long working hours










Understaffing

• Understaffing is directly related to a higher risk of adverse events for patients, including medication

errors.





Higher nurse-to-patient ratios


• Increase of one patient in a nurse’s workload increased the risk of death of one patient in that
hospital.

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System weaknesses










Deficiency in system management which has given or may give rise to an incident/accident.





Constitutes a medical error.


• An error is defined as the failure of a planned action to be completed as intended, or the use of a
wrong plan to achieve an aim

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Patient factors











Health literacy is “the degree to which individuals have the capacity to obtain, process, and
understand basic health information and services needed to make appropriate health decisions.”





It includes the ability to understand instructions on prescription bottles, appointment slips, medical

education brochures, doctors’ directions, and consent forms, and the ability to negotiate complex
healthcare systems

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Language Barrier










Language or communication barriers between patients and health professionals may negatively
impact medical care.





Interpretation from family members or untrained personnel is incorrectly translated.


➢ due to the precision of the vocabulary used in the interpretation.

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Elderly patient










• Poor cognition is associated with inability to follow medication regimens.

• Poor vision and decreased manual dexterity













The causes of prescribing errors in this patient population are multifaceted and complex,

including prescribers' lack of knowledge of aging physiology, geriatric medicine,
and geriatric pharmacotherapy, overprescribing that frequently leads to major polypharmacy

(> 5 medications), inappropriate prescribing, and inappropriate drug

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Paediatric Patients










Paediatric patients face four distinct issues that set them apart from the rest of the hospital population,
making it a high-risk environment for hospitalized children:





• Development. As children mature both mentally and physically, their needs for healthcare goods

and services change.


• Dependency. Hospitalized children are dependent on caregivers and parents to convey key
information and their care must be approved by parents or their surrogates during all encounters.


• Different epidemiology. Most hospitalized children require acute episodic care, not care for
chronic conditions as with adults.


• Demographics. Children are more likely to live in poverty and experience racial and ethnic
disparities in healthcare, and they are more dependent on public insurance


(Hughes & Blegen, 2008).

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ii. Medical Errors consequences










Errors - Complaint – Litigation





In medical litigation, the patient or his family are usually the plaintiffs while the doctor or
hospital is the defendant.






The range of consequences from medication error effects runs from no notable effects to death.


• It can cause a new condition, either temporary or permanent, such as itching, rashes, or skin
disfigurement.


• Also can result in severe patient injury or death.

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ii. Medical Errors consequences










Legally, hospitals could face huge legal counsel and possible settlement costs.

• Hospitals may also need to bear the loss of productivity from the staff involved in the error, and

the increased cost of unplanned prolonged hospitalisation and treatment of the patients.





Most medical errors do not result in a lawsuit, and many lawsuits do not involve an error.


• However, medical errors and lawsuits are often linked, as patients/families seek compensation
when there is a bad outcome

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AVOIDING ERRORS











i. Job scope

ii. Communication

iii. Optimal Documentation

iv. Common mistakes

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i. Job Scope










1. Know the job boundaries

2. Competency in core procedures


3. Ask for help/ assistance when in doubt

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ii. Communication










1. Communicative Aspect

• Verbal and Non verbal


• Same level of communications





2. Build a rapport between healthcare providers (HCP) and patients






3. Develop a trust with the patients

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ii. Communication










4. Verbal





• Be polite, Actively listen to the complainant;


• Empathize, understand and acknowledge their viewpoint;

• Express regret that they have had a poor experience, and assure them steps will be taken to

investigate and resolve their concerns.

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iii. Optimal Documentation










1. Integral part of medical practice

• “Any written or electronically generated info about patient that describes the care or service

provided to patient”

2. Facilitate communications


3. Promote good nursing care


4. Meet professional and legal standard

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iv. Common Mistakes










1. Abbreviations

2. Units (mg/mcg/g)


3. Illegible hand writing


4. No official stamp /signatures

5. Chronology / timing

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Summary











Working as healthcare provider, ones may experience Medical Error, Adverse Event And Near Misses.





To avoid these incidence, ones should know the causes of Medical error, adverse event, near misses
and its consequences.