Reducing medical error and

increasing patient safety

Richard Smith
Editor, BMJ
What I want to talk about

• A story
• How common is error?
• Why does error happen?
• How should we think of error?
• How should we respond?
A story
 How common is error?
• Harvard Medical Practice Study
• Reviewed medical charts of 30 121
patients admitted to 51 acute care
hospitals in New York state in 1984
• In 3.7% an adverse event led to
prolonged admission or produced
disability at the time of discharge
• 69% of injuries were caused by errors
 How common is medical error?
• Australian study
• Investigators reviewed the medical records
of 14 179 admissions to 28 hospitals in New
South Wales and South Australia in 1995.
• An adverse event occurred in 16.6% of
admissions, resulting in permanent
disability in 13.7% of patients and death in
4.9%
• 51% of adverse events were considered to
have been preventable.
How common is medical error?
• The differences between the US and
Australian results may reflect
different methods or different rates
• Other, smaller studies (including one
from Britain) show similar orders of
errors
• There are few studies from
outpatients or primary care
How common is medical error?
• An evaluation of complications
associated with medications among
patients at 11 primary care sites in
Boston.
• Of 2258 patients who had had drugs
prescribed, 18% reported having had a
drug related complication, such as
gastrointestinal symptoms, sleep
disturbance, or fatigue in the previous
year.
 Results of medical error
• In Australia medical error results in
as many as 18 000 unnecessary
deaths, and more than 50 000
patients become disabled each year.
• In the United States medical error
results in at least 44 000 (and
perhaps as many as 98 000)
unnecessary deaths each year and 1
000 000 excess injuries.
 Types of error
• About half of the adverse events
occurring among inpatients resulted
from surgery.
• Next come
– Complications from drug treatment
– therapeutic mishaps
– diagnostic errors were the most common
non-operative events. In the Australian
study cognitive errors, such as making an
 Types of error
• Cognitive errors--such as incorrect
diagnosis or choosing the wrong
medication-- more likely to have
been preventable and more likely to
result in permanent disability than
technical errors.
Which patients are most at risk?
• Those undergoing cardiothoracic
surgery, vascular surgery, or
neurosurgery
• Those with complex conditions
• Those in the emergency room
• Those looked after by inexperienced
doctors
• Older patients
 How dangerous is health care?
• Less than one death per 100 000 encounters
– Nuclear power
– European railroads
– Scheduled airlines
• One death in less than 100 000 but more than 1000
encounters
– Driving
– Chemical manufacturing
• More than one death per 1000 encounters
– Bungee jumping
– Mountain climbing
– Health care
 Why do errors happen?
• All humans make errors: indeed, “the
ability to make mistakes” allows human
beings to function
• Most of medicine is complex and uncertain
• Most errors result from “the system”--
inadequate training, long hours, ampoules
that look the same, lack of checks, etc
• Healthcare has not tried to make itself safe
 How to think of error?
• An individual failing
– Only the minority of cases amount from
negligence or misconduct; so it’s the
“wrong” diagnosis
– It will not solve the problem--it will
probably in fact make it worse because it
fails to address the problem
– Doctors will hide errors
– May destroy many doctors inadvertently
(the second victim)
 How to think of error?

• A systems failure
– This is the starting point for
redesigning the system and
reducing error
 How to respond? Tactics
• Reduce complexity
• Optimise information processing
– checklists, reminders, protocols
• Automate wisely
• Use constraints
– for instance, with needle connections
• Mitigate the unwanted side effects of change
– with training, for example.
 Building a safe healthcare
system (from James Reason)

• Principles
• Policies
• Procedures
• Practices
 Building a safe healthcare
system (from James Reason)
• Principles
– Safety is everybody’s business
– Top management accepts setbacks and
anticipates errors
– safety issues are considered regularly
at the highest level
– Past events are reviewed and changes
implemented
 Building a safe healthcare
system (from James Reason)
• Principles
– After a mishap management concentrates on
fixing the system not blaming the individual
– Understand that effective risk management
depends on the collection, analysis, and
dissemination of data
– Top management is proactive in improving
safety--seeks out error traps, eliminates
error producing factors, brainstorms new
scenarios of failure
 Building a safe healthcare
system (from James Reason)
• Policies
– Safety related information has direct
access to the top
– Risk management is not an oubliette
– Meetings on safety are attended by staff
from many levels and departments
– Messengers are rewarded not shot
– Top managers create a reporting culture
and a just culture
 Building a safe healthcare
system (from James Reason)
• Policies
– Reporting includes qualified
indemnity, confidentiality, separation
of data collection from disciplinary
procedures
– Disciplinary systems agree the
difference between acceptable and
unacceptable behaviour and involve
peers
 Building a safe healthcare
system (from James Reason)
• Procedures
– Training in the recognition and recovery of
errors
– Feedback on recurrent error patterns
– An awareness that procedures cannot
cover all circumstances; on the spot
training
– Protocols written with those doing the job
– Procedures must be intelligible, workable,
available
 Building a safe healthcare
system (from James Reason)

• Procedures
– Clinical supervisors train their
charges in the mental as well as the
technical skills necessary for safe
and effective performance
 Building a safe healthcare
system (from James Reason)
• Practices
– Rapid, useful, and intelligible feedback on
lessons learnt and actions needed
– Bottom up information listened to and
acted on
– And when mishaps occur
• Acknowledge responsibility
• Apologise
• Convince patients and victims that lessons
learned will reduce chance of recurrence
 James Reason’s bottom line

• Fallibility is part of the human

condition
• We can’t change the human
condition
• We can change the conditions under
which people work
 Conclusions
• Human beings will always make errors
• Errors are common in medicine,
killing tens of thousands
• We begin to know something about the
epidemiology of error, but we need to
know much more
• Naming, blaming and shaming have no
remedial value
 Conclusions
• We need to design health care
systems that put safety first
(First, do no harm)
• We know a lot about how to do that
• It’s a long, never ending job