Preventable Medical Errors Not Prevented Nearly Enough

One of the saddest things about many of the personal injuries and wrongful deaths that result from medical malpractice is that so many of these injuries are entirely preventable. Whether its a hospital’s failure to use appropriate safety protocols or a medical worker’s failure to comply with those protocols, far too many people suffer entirely preventable injuries.

Study Discusses Evidence-Based Estimate of Patient Harms Associated with Hospital Care The Journal of Patient Safety published a study by Dr. John T. James, PhD that provides information about preventable hospital injuries. In the study, Dr. James reviewed data from medical records of patients treated in New York Hospitals. The original study was based on data from 1984 but it has now been updated with numbers from studies from 2008 to 2011. The studies used what is called the “Global Trigger Tool” to flag certain evidence in medical records that may point to an adverse event that harms a patient. The review of these records allowed the study’s author to estimate that the true number of preventable patient deaths caused by hospital error is around 400,000 per year. Experts were also able to estimate that serious harm happens somewhere between ten and twenty times as often as lethal harm.

Factors Contributing to Preventable Adverse Events

The focus of the study was what the author calls “preventable adverse events” or PAEs. The paper offers many possible contributing factors that can result in these PAEs. One issue is that clinical research provides physicians with so much new information this year that individual physicians can become overwhelmed. Another issue is that our medical profession lacks a comprehensive and well integrated continuing education system. Guidelines to ensure patient safety become problematic when they fall out of date. Hospitals have staffing issues and at times lack the technology necessary to improve patient care. The United States lags behind other countries when it comes to electronic medical records and thus physicians sometimes lack vital information necessary to preventing mistakes in care. This is exacerbated by a system that often forces patients to bounce from one provider to another to obtain affordable care. Doctors feeling the pressure of higher production demands are also more likely to suffer from burnout and related performance issues.

Types of Preventable Adverse Events

The study divides the types of PAEs in hospitals into five different categories: (1)errors of commission, (2) errors of omission, (3) errors of communications, (4) errors of context, and (5) diagnostic errors. Some of these types of errors are easier to find in medical records than others. For example, errors of commission are the easiest to find. These errors occur when a mistaken action harms a patient because either it was the wrong action to take or it was the right action but it was performed improperly. Errors of omission can be found in records where an obvious action was necessary to treat a patient, but that action was not taken for whatever reason. Contextual errors are errors that occur when a doctor fails to take the unique constraints of a patient’s life into account when prescribing treatment.

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