Adverse events and medical errors
- Definitions
- Adverse Event: Any injury caused by medical management (rather than underlying disease); may or may not be preventable
- Medical Error: Failure of a planned action to be completed as intended OR use of a wrong plan to achieve an aim
- Near Miss: Error that could have caused harm but did not reach the patient (intercepted or by chance)
- Sentinel Event: Unexpected occurrence involving death or serious physical/psychological injury
- Types of Errors
- Active Errors: Occur at point of contact between human and system (e.g., wrong medication administered by nurse)
- Latent Errors: System/organizational failures that create conditions for active errors (e.g., poor labeling, inadequate staffing)
- Diagnostic Errors: Missed, delayed, or incorrect diagnosis
- Treatment Errors: Wrong medication, dose, route, or procedure
- Preventive Errors: Failure to provide prophylaxis or monitoring
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