To make no mistakes is not in the power of man; but from their errors and mistakes, the wise and good learn wisdom for the future. Plutarch
In a perfect world, physicians would never get tired and never get stymied by a patient with an unusual symptom. They wouldn’t have to hand-off their patients to the doctor working the next shift and nurses would communicate instructions to each other with perfect clarity. Sadly, the real world is far more error-prone, and while most medical errors are small harmless slip-ups, occasionally they balloon into full-blown tragedies. While patients know that doctors will not always be able to cure them, they do expect that they will at least not be harmed; and that the treatment will not be worse than the disease. Medical errors are the dark side of medical progress, a consequence of the ever-increasing complexity of modern medicine. However, there’s a lot we can do to reduce their frequency and impact, and there are plenty of success stories we can learn from. One of the reasons the field of patient safety is vexing is that it takes a uniquely interdisciplinary effort to protect patients from harm -one in which hospital CEOs, doctors, nurses, pharmacists, managers, administrators and patients forge new relationships and combine their strengths to overcome weaknesses.
In the early years of the safety field, the target was errors, and we focused on measuring and decreasing error rates. This model has given way to a new focus on measuring and attacking “harm” or “adverse events” where harm is the “outcome” and errors are the “process.” After all, patients, quite naturally, care more about what happens to them than whether their doctor or nurse made a mistake. We need to differentiate complications (adverse events that arise from the underlying disease) from medical harm (unintended injury caused by medical care). Not all adverse events are preventable, and those that are, usually involve errors. An error is “an act of commission (doing something wrong) or omission (failing to do the right thing) which may lead to or which causes an undesirable outcome.” Many errors do not result in adverse events and these are called ‘near misses’ or ‘close calls’. When the error is a result of care that falls below a professional standard of care, it’s called negligence. Harm-Any physical or psychological injury or damage to the health of a person, either temporary or permanent. Harm is usually classified as no harm, low harm, moderate harm, severe harm or death.
- Any patient safety incident that had the potential to cause harm but was prevented, resulting in ‘no harm’
Adverse event or error
- An event involving unintended harm to a patient that resulted from medical care. Traditionally, the term used for an adverse event was ‘iatrogenesis”.
Preventable adverse event
- An adverse event due to error. Harm is caused either by a wrong or inappropriate action (‘error of commission’) or by failure to do the right thing (‘error of omission’).
Patient safety incident
- Any unintended or unexpected incident that could have harmed or did harm the patient. This includes ‘near misses’. The term ‘patient safety incident’ is preferred to “error”, as the latter has a more negative connotation.
- Freedom from accidental injury. We need to establish systems to decrease errors, and to intercept them when they occur.
- Any set of circumstances which significantly increases the likelihood of an error.
Venn diagram depicting the relationship between errors, complications and negligence.
Learning from our mistakes
We need to openly acknowledge that errors are an integral part of the human experience. This will allow us to radically transform our approach to medical error. After all, one of the best ways to improve oneself is to recognize mistakes and to learn from them. The same strategy applies to providing the best patient care possible, and we need to treat medical errors as a treasure, rather than try to hide them, or shy away from discussing them. Medical care can be a double-edged sword. While doctors can save lives, they can also end up harming patients. This unnerving fact that healthcare can harm us as well as heal us is the reason why patient safety lies at the core of healthcare quality. While effectiveness, access to care, timeliness and the other dimensions of quality are all very important, safety is always the topmost priority. At least 1 in 10 hospital admissions are marred by an adverse event, and about half of these are preventable. About one-third of these adverse events cause true patient harm. The fact that the harm was not deliberate is cold comfort for the patient who was at the receiving end. Medical errors can result in permanent injury, and even death. The real tragedy is when the harm could have been prevented, but was not! We cannot afford to turn a blind eye to these errors, or adopt a “chalta hai” attitude. While it’s easy to look for a scapegoat and blame the doctor and hospital when something goes wrong, the truth is that medical errors do not necessarily occur because doctors are callous or careless. The current healthcare system is complex and overloaded; it means that the successful outcome of a medical procedure depends on a range of factors, and not just the competence of a particular doctor! With so many variables and healthcare personnel (doctors, nurses, pharmacists, lab technicians, dieticians etc) involved in the care of one individual, it’s no surprise that patient safety can sometimes become a casualty. Problems can snowball, and the term “toxic cascades” describes how small errors which trickle by unnoticed can eventually add up to become torrents.
What is the difference between patient safety and quality?
Patient safety is an important element of an effective, efficient health care system where quality prevails. These two factors go hand-in-hand; there can never be any quality without safety! Here’s how you can break it down: * Safety has to do with lack of harm. Quality has to do with efficient, effective, purposeful care that gets the job done at the right time. * Safety focuses on avoiding bad events. Quality focuses on doing things well. * Safety makes it less likely that mistakes happen. Quality raises the ceiling so the overall care experience is a better one. The ‘patient safety first’ culture needs to become part of the DNA of the healthcare system. This means committing to safety at all levels of the health facility, right from the frontline staff to doctors and nurses as well as the board of directors.
Medical errors from the doctor’s perspective
There are times when we doctors forget about the real identities of the people we address as “patients.” We talk about them with clinical detachment, often presenting them as “cases” to colleagues. We forget that they, like us, are made of flesh and blood, have families, jobs and responsibilities, dreams, aspirations and the desire to get healthy and move on with their lives ! Medical errors are not mere statistics. When we encounter an error, we should put ourselves in our patients’ shoes and learn to ask, “How do I prevent this from happening again?” Behind each event there’s a real-life story about patients and their loved ones. Some patients who have been harmed by medical errors may take legal action against the doctors who provided them care, and there’s a separate story about the doctors and nurses whose lives and careers are torn apart, because of faulty systems and processes. Doctors too will become patients one day. We will fall ill, and will need consultation, diagnosis and medical care, just as every other mortal does. As doctors, we know a lot about everything that can go wrong, and this can create a lot of anxiety, nervousness and fear in our hearts. It’s probably only when we are at the receiving end that we realize how important patient safety is. Although human error will always remain an ‘uncontrollable’ variable in the delivery of healthcare, there’s a lot we can do to minimize errors.