Adverse events and medical errors

Definitions

• Medical error: an action or failure to act that exposes a patient to possible harm in the context of medical care, regardless of whether or not harm actually occurs; focuses on the process (the misstep or omission).
• Adverse event: an unintended harmful consequence of a medical treatment, which may or may not be the result of a medical error; focuses on the outcome (actual harm done to the patient).

Classification of medical errors

• Active error
  • Occurs at level of frontline operator (eg, wrong IV pump dose programmed)
  • Immediate impact
• Latent error
  • Occurs in processes indirect from operator but impacts patient care (eg, different types of IV pumps used within same hospital)
  • Accident waiting to happen

Classification of adverse events

• Preventable adverse event
  • Any adverse event that is due to a medical error
  • A patient is given a medication to which they are allergic because their allergy information was never documented in the chart.
• Ameliorable adverse event
  • An unpreventable adverse event that could have been reduced in severity through specific actions
  • A patient's correctly placed IV subsequently becomes infiltrated (unpreventable), but this is not discovered for a number of hours because of understaffing
• Never event
  • Adverse event that is identifiable, serious, and usually preventable (eg, scalpel retained in a surgical patient's abdomen)
  • Major error that should never occur
  • Sentinel event—a never event that leads to death, permanent harm, or severe temporary harm
    • Their occurrence can reveal vulnerabilities in the healthcare system
• Near miss
  • Unplanned event that does not result in harm but has the potential to do so (eg, pharmacist recognizes a medication interaction and cancels the order)
  • Narrow prevention of harm that exposes dangers

Management of medical errors

• Initial disclosure
  • Acknowledge errors openly
  • Do not hide errors or other relevant factors
  • Express empathy & give apology as appropriate
  • Avoid blaming or denigrating other team members & providers
  • Allow adequate opportunity for patient questions
• Follow-up steps
  • Remain engaged in the patient's care
  • Outline steps to prevent future occurrence