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Guest Essay

The Cruel Lesson of a Single Medical Mistake

By Daniela J. Lamas

Dr. Lamas, a contributing Opinion writer, is a pulmonary and critical-care physician at Brigham and Women’s Hospital in Boston.

We all carry the memory of our mistakes. For health care workers like me, these memories surface in the early morning when we cannot sleep or at a bedside where, in some way, we are reminded of a patient who came before. Most were errors in judgment or near misses: a procedure we thought could wait, a subtle abnormality in vital signs that didn’t register as a harbinger of serious illness, an X-ray finding missed, a central line nearly placed in the wrong blood vessel. Even the best of us have stories of missteps, close calls that are caught before they ever cause patient harm.

But some are more devastating. RaDonda Vaught, a former Tennessee nurse, is awaiting sentencing for one particularly catastrophic case that took place in 2017. She administered a paralyzing medication to a patient before a scan instead of the sedative she intended to give to quell anxiety. The patient stopped breathing and ultimately died.

Precisely where all the blame for this tragedy lies remains debated. Ms. Vaught’s attorney argued his client made an honest mistake and faulted the mechanized medication dispensing system at the hospital where she worked. The prosecution maintained, however, that she “overlooked many obvious signs that she’d withdrawn the wrong drug” and failed to monitor her patient after the injection.

Criminal prosecutions for medical errors are rare, but Ms. Vaught was convicted in criminal court of two felonies and now faces up to eight years in prison. This outcome has been met with outrage by doctors and nurses across the country. Many worry that her case creates a dangerous precedent, a chilling effect that will discourage health care workers from reporting errors or close calls. Some nurses are even leaving the profession and citing this case as the final straw after years of caring for patients with Covid-19.

From my vantage point, it is not useful to speculate about where malpractice ends and criminal liability begins. But what I do know as an intensive care unit doctor is this: The pandemic has brought the health care system to the brink, and the Vaught case is not unimaginable, especially with current staffing shortages. That is, perhaps, the most troubling fact of all.

It has been more than 20 years since the Institute of Medicine released a groundbreaking report on preventable medical errors, arguing that errors are due not solely to individual health care providers but also to systems that need to be made safer. The authors called for a 50 percent reduction in errors over five years. Even so, there is still no mandatory, nationwide system for reporting adverse events from medical errors.

When patient safety experts talk about medical errors in the abstract, in lecture halls and classrooms, they talk about a culture of patient safety, which means an openness to discussing mistakes and safety concerns without shifting to individual blame. In reality, however, conversations around errors often have a different tone. Early in my intern year, a senior cardiologist gathered our team one morning, after one of my fellow interns failed to start antibiotics on a septic patient overnight. The intern had been busy with a sick new admission and had missed subtle changes in the now septic patient, who had spiraled into shock by the morning.

“You must never stop being terrified,” the attending doctor told us. Even after decades of practice, she remained in a constant state of high alert. When you allow yourself to neglect your usual compulsiveness, she said, that’s when mistakes happen. Not because of imperfect systems, overwork and divided attention but because an intern was not appropriately terrified.

I carried her words with me for years. I have repeated them to my own residents. And there is a truth here: The cost of distraction on our job can be life or death, and we cannot forget that. But I realize now that no one should have to maintain constant terror. Mistakes happen, even to the most vigilant, particularly when we are juggling multiple high-stress tasks. And that is why we need robust systems, to make sure that the inevitable human errors and missteps are caught before they result in patient harm.

The electronic health records we use now prompt doctors and nurses when patients’ combinations of vital signs and lab results suggest that they might be septic. This can be frustrating when we are fatigued by alarms and alerts, but it helps us recognize and react to patterns that a busy medical team might otherwise miss. When it comes to administering medications, they must generally be approved by a pharmacist before they can become available to a nurse to administer. Some hospitals create a no-talk zone where nurses withdraw these medications, because that process requires a focus that is often impossible in the frenzy of today’s hospitals.

Once the medication is in hand, nurses use a system to scan the drug along with the patient’s wristband to help ensure that the correct medication is given to the correct patient. None of these systems are perfect. But each serves to acknowledge that no individual can hold full responsibility for every step that leads to a patient outcome. Just being vigilant is not enough.

What’s needed alongside these systems is a culture in which doctors and nurses are empowered to speak up and ask questions when they are uncertain or when they suspect that one of their colleagues is making a mistake. This could mean that a nurse questions a doctor’s medication order and discovers it was intended for a different patient. Or that a junior doctor admits she is out of her depth when faced with a procedure that she should know how to do.

Stories in medicine so often celebrate an individual hero. We valorize the surgeon who performs the groundbreaking surgery but rarely acknowledge the layers of teamwork and checklists that made that win possible. Similarly, when a patient is harmed, it is natural to look for a person to blame, a bad apple who can be punished so that everything will feel safe again. It is far easier and more palatable to tell a story about a flawed doctor or a nurse than a flawed system of medication delivery and vital sign management.

But when it comes to medical errors, that is rarely the reality. Health care workers and the public must acknowledge that catastrophic outcomes can happen even to well-intentioned but overworked doctors and nurses who are practicing medicine in an imperfect system. Punishing one nurse does not ensure that a similar tragedy won’t occur in a different hospital on a different day. And regardless of the sentence that Ms. Vaught receives in May and whether it is fair, her case must be viewed as a story not just about individual responsibility but also about the failure of multiple systems and safeguards. That is a harder narrative to accept, but it is a necessary one, without which medicine will never change. And that, too, would be a tragic error but one that is still in our power to prevent.

Daniela J. Lamas ( @danielalamasmd) , a contributing Opinion writer, is a pulmonary and critical-care physician at Brigham and Women’s Hospital in Boston.

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Medical Errors: Overview

• Living reference work entry
• First Online: 28 November 2023
• Cite this living reference work entry

• Yaser Mohammed Al-Worafi   ORCID: orcid.org/0000-0002-5752-2913 2 , 3  

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Medical errors are a global concern, and their impact is particularly significant in developing countries. This chapter describes the prevalence, causes, prevention, management, challenges, and recommendations related to medical errors in developing countries. Medical errors arise from various factors, including communication breakdowns, diagnostic errors, medication-related issues, surgical errors, and systemic challenges. Preventive strategies encompass effective communication, standardized protocols, patient engagement, and a culture of safety. Managing medical errors necessitates prompt response, thorough investigation, learning from mistakes, and implementation of preventive measures. Challenges in developing countries, such as limited resources and infrastructure, pose unique obstacles. Recommendations include enhancing healthcare infrastructure, promoting patient safety policies, strengthening workforce capacity, improving access to technology, and fostering collaborations. These efforts can contribute to reducing medical errors and improving patient safety in developing countries.

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Al-Worafi, Y.M. (2024). Medical Errors: Overview. In: Al-Worafi, Y.M. (eds) Handbook of Medical and Health Sciences in Developing Countries . Springer, Cham. https://doi.org/10.1007/978-3-030-74786-2_276-1

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DOI : https://doi.org/10.1007/978-3-030-74786-2_276-1

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ORIGINAL RESEARCH article

First, do no harm (gone wrong): total-scale analysis of medical errors scientific literature.

• 1 Ludwig Boltzmann Institute for Digital Health and Patient Safety (LBIDHPS), Medical University of Vienna, Vienna, Austria
• 2 Institute of Genetics and Animal Biotechnology of the Polish Academy of Sciences, Magdalenka, Poland
• 3 Institute of Neurobiology, Bulgarian Academy of Sciences, Sofia, Bulgaria
• 4 Department of Pharmacognosy, University of Vienna, Vienna, Austria
• 5 Oral and Maxillofacial Radiology, Applied Oral Sciences and Community Dental Care, Faculty of Dentistry, The University of Hong Kong, Hong Kong, China
• 6 Division of Pediatric Nephrology and Gastroenterology, Department of Pediatrics and Adolescent Medicine, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
• 7 Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University Vienna, Vienna, Austria

Objective: Medical errors represent a leading cause of patient morbidity and mortality. The aim of this study was to quantitatively analyze the existing scientific literature on medical errors in order to gain new insights in this important medical research area.

Study Design: Web of Science database was used to identify relevant publications, and bibliometric analysis was performed to quantitatively analyze the identified articles for prevailing research themes, contributing journals, institutions, countries, authors, and citation performance.

Results: In total, 12,415 publications concerning medical errors were identified and quantitatively analyzed. The overall ratio of original research articles to reviews was 8.1:1, and temporal subset analysis revealed that the share of original research articles has been increasing over time. The United States contributed to nearly half (46.4%) of the total publications, and 8 of the top 10 most productive institutions were from the United States, with the remaining 2 located in Canada and the United Kingdom. Prevailing (frequently mentioned) and highly impactful (frequently cited) themes were errors related to drugs/medications, applications related to medicinal information technology, errors related to critical/intensive care units, to children, and mental conditions associated with medical errors (burnout, depression).

Conclusions: The high prevalence of medical errors revealed from the existing literature indicates the high importance of future work invested in preventive approaches. Digital health technology applications are perceived to be of great promise to counteract medical errors, and further effort should be focused to study their optimal implementation in all medical areas, with special emphasis on critical areas such as intensive care and pediatric units.

Introduction

Medical errors are a leading cause of patient morbidity and mortality. Recent mortality analysis in the United States ranked medical errors as the third major cause of death, following heart disease and cancer, which were ranked on the first and second place, respectively ( 1 ). A recent meta-analysis of 70 studies involving a total of 337,025 patients revealed that the average rate of preventable patient harm was 6%, of which 12% was severe or led to death ( 2 ). The same study also revealed that errors related to drugs (25%) and other treatments (24%) were the largest sources of preventable patient harm, and incidents were more likely to occur in advanced specialties (intensive care or surgery) in comparison to general hospitals ( 2 ).

Aside from patient harms and suffering, medical errors contribute to adverse mental and emotional effects on patient relatives and involved healthcare providers ( 3 ). Moreover, medical errors result in significant economic burden due to additional healthcare costs and lost productivity from missed workdays ( 4 ).

While sometimes medical errors have been scientifically reviewed and specifically examined in relation to the presence of adverse patient outcomes or injury, a more general definition is not linked to outcomes. Upon systematically examining this research area, Grober and Bohnen have proposed a more extensive definition of medical errors being “an act of omission or commission in planning or execution that contributes or could contribute to an unintended result” ( 5 ).

Better understanding of medical errors can be of a great importance because it may yield approaches aiming at their reduction. In this context, systematic analysis of the existing scientific literature in that area is of potentially high significance. Bibliometric analysis is a versatile approach involving evaluation of different parameters related to published literature, and its application can yield quantitative information reveling, e.g., prevailing research themes, characteristics and temporal trends (globally or within a specific scientific area), and impactful research studies, authors, and institutions (based on citation analysis) ( 6 – 9 ). Applied to the medical errors research literature, such insights can be of high value for both researchers and non-experts for rapid orientation and navigation within this scientific field and for the identification of relevant topics, trends, experts, and potential collaborator-candidates. Thus, because the existing scientific literature on medical errors has not yet been evaluated utilizing a bibliometric approach on a total scale, the aim of this work was to identify and bibliometrically analyze the relevant literature in order to gain new insights into this important medical research area.

Data Sources

In January 2020, Web of Science (WoS) Core Collection ( https://webofknowledge.com ) database was queried in order to identify relevant publications concerning the targeted scientific area using the following search strategy: TOPIC = (“medic * error * ”) OR (“medic * mistake * ”) OR (“mistake * in medic * ”) OR (“error * in medic * ”) OR (“healthcare * error * ”) OR (“healthcare * mistake * ”) OR (“mistake * in healthcare * ”) OR (“error * in healthcare * ”) OR (“preventable patient harm * ”) OR (“preventable harm * in healthcare * ”). This search strategy identified articles containing medical/healthcare (or derivatives of these words) in combination with error/mistake (or derivatives of these words, including plural forms, i.e., errors/mistakes) in the publication titles, abstracts, or keywords. No additional filters were used for the search.

Definitions and Data Extraction

Relevant publications were defined as those fulfilling the search criteria indexed in WoS at the time of the search. For this study, countries/regions were defined as the geographic locations listed by WoS that were based on the addresses of the author's affiliations (institutions). The publication type was defined as the document classification tagged by WoS to each of the publications, e.g., article, review, etc. The WoS categories referred to the journal categories assigned to each journal by WoS, so that one journal could belong to multiple categories.

The complete data set was extracted from WoS by the “Export Records to File” function. A maximum of 500 records in “Full Record and Cited References” were exported at a time, in the file format “Tab-delimited (Mac).” The procedure was repeated until the whole data set was covered. Initial bibliographic data were extracted with the WoS “Analyze Results” and “Create Citation Report” features.

The 10 most productive authors, institutions, countries/regions, journals, and WoS categories were identified for the all-time data sets. The number of publications ( n ), share of the total publication of the respective period (%), citations per publication (CPP), H index (except for journals), and impact factor (only for journals) were recorded.

The bibliographic data sets were loaded into VOSviewer, a bibliometric software, to relate citation data and words appearing in the titles/abstracts for four time periods: all-time, the 1990s and before, the 2000s, and since the 2010s. Only words recurring in >1% of the publications in the respective data sets were analyzed and visualized. The relationship was similarly analyzed with author keywords recurring in >0.5% of the publications in the respective data sets. Bubble maps were generated to illustrate the changes in the literature.

In total, 12,415 publications concerning medical errors were indexed in WoS, dating back to 1961 and accumulating gradually ever since, surpassing 1,000 total publications in 2003 and 10,000 in 2017 ( Figure 1 ). There were 358 articles published in the 1990s and before, 3,705 articles in the 2000s, and 8,352 articles since the 2010s. Overall, 70.9% of the publications were original articles and 8.8% were reviews, resulting in a ratio of 8.1:1 ( Figure 2 ). The ratio of original articles increased from 55.9% in the 1990s and before, up to 72.4% since the 2010s. Simultaneously, the ratio of reviews also increased from 2.2 up to 10.3%, whereas the ratio of letters and editorial materials declined.

Figure 1 . Cumulative publication count of medical errors literature over time.

Figure 2 . Trends in the ratio of various publication types.

The all-time 10 most productive authors, institutions, countries/regions, journals, and WoS journal categories are listed in Table 1 . Eight of the top 10 institutions were from the United States, and one each in Canada and the United Kingdom. The United States had contributions to nearly half of the total publications. The American Journal of Health-System Pharmacy (impact factor 2.012) was the most productive journal. In addition, publication shares of “pharmacology pharmacy” and “medicine general internal” journals decreased over the decades, whereas the shares of “healthcare sciences services” and “nursing” journals surged ( Figure 3 ).

Table 1 . The all-time 10 most productive authors, institutions, countries/regions, journals, and journal categories.

Figure 3 . Trends in the publication share of various Web of Science journal categories.

The 10 most recurring and most cited terms for all-time and each time period are listed in Table 2 . The medication error was one of the most frequently mentioned types of medical errors, and “adverse drug event” was the term associated with the highest citation rate of the associated publications. Together with adverse drug events (ADEs), computerized physician order entry (CPOE) and burnout (of healthcare providers) are also among the topics associated with high average citations. Bubble maps are shown in Figure 4 to illustrate the changes of prevailing terms in the literature body over time. Meanwhile, the 10 most recurring and on average most cited author keywords are listed in Table 3 . Consistently, medication errors were frequently listed and together with CPOE and ADE were associated with high citation rates of the respective manuscripts. Besides, publications concerning critical care, intensive care units, and children/pediatrics were also highly cited. To supplement these findings, the all-time top 10 most cited publications concerning medical errors are listed in Table 4 . Half of them were published in the Journal of the American Medical Association .

Table 2 . The 10 terms with the highest appearance ( n ) and citations per publication (CPP) for all-time and different time periods, respectively.

Figure 4 . The use of terms in the titles and abstracts of the publications during (A) the 1990s and before, (B) the 2000s, and (C) since the 2010s. The color of the bubbles indicates the citations per publication (CPP) containing the terms; the bubble size indicates the number of publications and the distance between the bubbles indicates the frequency of co-occurrence of the terms.

Table 3 . The 10 author keywords with highest appearance ( n ) and citations per publication (CPP) for all-time and different time periods, respectively.

Table 4 . Top 10 most cited medical errors publications.

In this work, we have identified and bibliometrically analyzed 12,415 publications concerning medical errors.

The performed temporal publication number analysis ( Figure 1 ) revealed steady growth of the body of literature dealing with medical errors, identifying this research area to be of increasing scientific interest. The trend line of publication counts plotted against time ( Figure 1 ) reveals that the numbers of publications in this area increased linearly with a slower rate until 1999, exponentially increased in the period 2000–2010, and again went into steady but more rapid linear-increase mode since 2010. The exponential increase in publications in the decade following 1999 is likely to be triggered and highly influenced by the landmark report To Err Is Human published by the Institute of Medicine in 1999 ( 10 , 11 ). The growth rate of medical errors literature ( Figure 1 ) is faster than that of another recently analyzed scientific area with perceived high importance, food toxicology ( 12 ), and resembles the growth rate identified to occur with antioxidant research literature ( 13 ). Mirroring the three time periods of different growth rate of the literature body on medical errors (as identified in the trend line presented in Figure 1 ), further analysis was focused on comparison of features of the literature subsets published in the three respective periods: (i) the 1990s and before; (ii) the 2000s, and (iii) since the 2010s.

In respect to the type of publication ( Figure 2 ), we noted that 70.9% of the total publications were original research articles, whereby the temporal analysis in the three time periods revealed an increasing share of original research articles with 55.9% in the 1990s and before, 68.7% in the 2000s, and 72.4% since the 2010s. Despite this trend indicating increasing amount of original research in the scientific area of medical errors, the total share of 70.9% is still a bit lower than the original research article shares of other recently analyzed biomedical scientific fields such as neuropharmacology (original research articles share of 72.3%) ( 14 ), biotechnology (73.2%) ( 7 ), and ethnopharmacology (84.6%) ( 15 ). Probably this lower share of original research articles is due to the intrinsic difficulties associated with the medical errors field of research (e.g., difficulties in reliable identification of medical errors, differences and discrepancies in definitions and used terminology, and diverse complicating societal, legal, ethical, economical, and behavioral aspects) ( 16 – 18 ).

Concerning authorship of the medical error literature, examination of the all-time top 10 list presented in Table 1 reveals that the most productive author by far (182 publications, almost 3-fold more than the second author on the list) was David W. Bates. Professor Bates also was the leader concerning H index of the analyzed medical error publications (H index = 61) and had the second highest CPP (CPP = 96.1) among the top 10 most productive authors. Professor Bates has made major contributions in the area of application of information technology to patient safety, outcome assessment, and quality of care, including CPOE implementation ( 19 ). Remarkably, around half (46.4%) of all medical error publications were affiliated with the United States (being also the home country of Professor Bates), where 8 out of the top 10 most productive institutions were located ( Table 1 ). While the United States is clearly one of the leading countries in terms of scientific productivity in many different research areas, its publication share (46.4%) in the medical errors literature is clearly higher than the shares of publications affiliated with the United States in other scientific areas with medical relevance such as Alzheimer disease (39.4%) ( 20 ), bariatric surgery (39.3%) ( 21 ), and neuropharmacology (38.0%) ( 14 ).

In respect to commonly discussed and highly cited topics in the medical errors literature ( Table 2 ), prevailing themes are revealed by the common use/citation rate of terms related to drug administration (“medication error,” “medication error prevention,” “medication,” “serious medication error,” “medication order,” “drug,” “adverse drug event”), mental conditions (in the healthcare professionals or the affected patients) that might be associated with medical errors (“depression,” “burnout”), and medical information technology (“CPOE”; terms associated with medical literature databases: “EMBASE,” “MEDLINE,” “CINAHL”). The high percentage of publications referencing medications and associated terminology is in line with the known high share (25%) of errors related to drugs as a source of preventable patient harm ( 2 ). Analysis of the bubble maps ( Figure 4 ) of the prevailing terms in the three analyzed periods also indicate diversification of research topics (increased number of bubbles) with the progression of time. This observation can be linked with the higher share of publications related to “medication error” in the first analyzed time period (53.4%, representation of the term by the biggest bubble in the graph depicting the time period “1990s and before”). While in the next two periods the share of publications referencing “medication error” decreased (to 31.7 and 32.8%, respectively), many new term-bubbles appeared, supporting the noted diversification of research themes. This shift associated with a decreased share of medication error-related publications might also be the reason for the decreasing share of articles published in journals of the category “pharmacology pharmacy” ( Figure 3 ).

Analysis of publication keywords listed by the authors ( Table 3 ) confirms the prevalence and importance of themes related to medications (“medication error,” “medication errors,” “adverse drug event,” etc.), mental health conditions (“burnout”), and digital health technology (“CPOE,” “computers,” “databases,” “CPOE”). The known high share of medical errors in advanced specialties (e.g., intensive care) ( 2 ) is also consistent with the high citation rate and prevalence of keywords such as “critical care” (CPP = 25.8; keyword listed in 0.8% of all analyzed publications) and “intensive care unit” (CPP = 24.7; listed in 0.7% of all analyzed publications). Interestingly, publications having a keyword “children” were also among the highest cited (CPP = 24.1). The high importance (reflected by high citation rate) of literature dealing with medical errors in children becomes evident when taking into consideration that there is much less research studying medical errors and preventable harms in children than in adults ( 2 ), but the rates of preventable ADE and potential ADE in pediatric inpatients might be in the same range or even higher than in adults ( 22 – 24 ).

The characteristics of the top 10 most cited publications ( Table 4 ) ( 22 , 25 – 33 ) provide further affirmations and rationalizations that can be linked to some of the major findings from the analysis of the entire medical errors publications set: Professor Bates, the most productive author, was in the author list of half of the 10 most cited publications ( 22 , 27 , 29 , 31 , 33 ), and a significant share of this 10 publications was focused on topics identified as highly impactful/prevailing, including applications of medical information technology/CPOE ( 25 , 27 , 28 , 32 , 33 ), and medical errors related to medications/ADE ( 22 , 27 , 28 , 31 ), intensive care units ( 29 ), children ( 22 ), or burnout among physicians ( 30 ).

Limitations

The search strategy utilized in this work identifies a well-defined literature set referring to medical errors in the WoS database. However, it should be noted that relevant articles only containing different terms of relevance, for example, “surgery errors” or “diagnostic mistakes,” are not identified by our approach and are therefore not included in this analysis. We did not include word combinations other than medical/healthcare errors/ mistakes (and variations/combinations thereof) in the search strategy in order to not introduce bias in our study. For example, adding “surgery errors” to the search strategy would have yielded additional relevant articles, but at the same time would have resulted in the specific enrichment of the yielded literature set with surgery-related articles. This would have prevented an unbiased estimation of the prevalence of the theme “surgery” within the medical errors literature. Moreover, relevant scientific articles from emerging journals that are not yet indexed in WoS are also not covered in our analysis. Merging of citation data originating from different databases cannot be done unbiasedly because each database collects citation counts differently. Web of Science was chosen for an unbiased total-scale analysis of the literature on medical errors as it represents the most referred and qualitatively reliable database of scientific literature, which is also used as a basis for the most established calculation of journal impact factors [Journal Citation Reports (JCR)]. Finally, it should be noted that while this work represents analysis of the global scientific literature, with the United States contributing to around half of all publications and with the following three highest-contributing countries also being first-world and English-speaking (England, Canada, Australia), the analysis outcomes are heavily influenced by this subset of the global population.

Conclusions

The analysis of literature concerning medical errors indicates that applications related to digital health technology (e.g., CPOE), and errors related to drugs/medications/ADE, to mental conditions (burnout, depression) in healthcare professionals associated with medical errors, to advanced specialties (e.g., intensive care), and to children/pediatrics, represent themes of leading importance. Consequently, of especially high impact might be future research on the interface of several of these prevailing themes (e.g., the application of digital applications to monitor the mental health status of healthcare professionals in pediatric intensive care units).

Data Availability Statement

All datasets generated in this study are included in the article/supplementary material.

Author Contributions

AA, AY, MK-P, and HW: conceived and designed the study. AY: extracted and analyzed the data. AA and AY: drafted the initial manuscript draft. AA, AY, EK, FE, ES, MK-P, and HW: critically revised the manuscript, interpreted data, and approved the final manuscript. All authors contributed to the article and approved the submitted version.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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28. Koppel R, Metlay JP, Cohen A, Abaluck B, Localio AR, Kimmel SE, et al. Role of computerized physician order entry systems in facilitating medication errors. J Am Med Assoc. (2005) 293:1197–203. doi: 10.1001/jama.293.10.1197

29. Landrigan CP, Rothschild JM, Cronin JW, Kaushal R, Burdick E, Katz JT, et al. Effect of reducing interns' work hours on serious medical errors in intensive care units. N Engl J Med. (2004) 351:1838–48. doi: 10.1056/NEJMoa041406

30. Shanafelt TD, Boone S, Tan L, Dyrbye LN, Sotile W, Satele D, et al. Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Arch Intern Med. (2012) 172:1377–85. doi: 10.1001/archinternmed.2012.3199

31. Gurwitz JH, Field TS, Harrold LR, Rothschild J, Debellis K, Seger AC, et al. Incidence and preventability of adverse drug events among older persons in the ambulatory setting. J Am Med Assoc. (2003) 289:1107–16. doi: 10.1001/jama.289.9.1107

32. Ash JS, Berg M, Coiera E. Some unintended consequences of information technology in health care: the nature of patient care information system-related errors. J Am Med Informatics Assoc. (2004) 11:104–12. doi: 10.1197/jamia.M1471

33. Bates DW, Gawande AA. Improving safety with information technology. N Engl J Med. (2003) 348:2526–34. doi: 10.1056/NEJMsa020847

Keywords: medical errors, bibliometric analysis, adverse drug events, patient safety, public health

Citation: Atanasov AG, Yeung AWK, Klager E, Eibensteiner F, Schaden E, Kletecka-Pulker M and Willschke H (2020) First, Do No Harm (Gone Wrong): Total-Scale Analysis of Medical Errors Scientific Literature. Front. Public Health 8:558913. doi: 10.3389/fpubh.2020.558913

Received: 04 May 2020; Accepted: 17 September 2020; Published: 16 October 2020.

Reviewed by:

Copyright © 2020 Atanasov, Yeung, Klager, Eibensteiner, Schaden, Kletecka-Pulker and Willschke. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Atanas G. Atanasov, atanas.atanasov@univie.ac.at ; Andy Wai Kan Yeung, ndyeung@hku.hk ; Harald Willschke, harald.willschke@meduniwien.ac.at

† These authors have contributed equally to this work

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

Suffering in Silence: Medical Error and its Impact on Health Care Providers

Affiliations.

• 1 Department of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia.
• 2 San Antonio Military Medical Center, Fort Sam Houston, Texas.
• PMID: 29366616
• DOI: 10.1016/j.jemermed.2017.12.001

Background: All humans are fallible. Because physicians are human, unintentional errors unfortunately occur. While unintentional medical errors have an impact on patients and their families, they may also contribute to adverse mental and emotional effects on the involved provider(s). These may include burnout, lack of concentration, poor work performance, posttraumatic stress disorder, depression, and even suicidality.

Objectives: The objectives of this article are to 1) discuss the impact medical error has on involved provider(s), 2) provide potential reasons why medical error can have a negative impact on provider mental health, and 3) suggest solutions for providers and health care organizations to recognize and mitigate the adverse effects medical error has on providers.

Discussion: Physicians and other providers may feel a variety of adverse emotions after medical error, including guilt, shame, anxiety, fear, and depression. It is thought that the pervasive culture of perfectionism and individual blame in medicine plays a considerable role toward these negative effects. In addition, studies have found that despite physicians' desire for support after medical error, many physicians feel a lack of personal and administrative support. This may further contribute to poor emotional well-being. Potential solutions in the literature are proposed, including provider counseling, learning from mistakes without fear of punishment, discussing mistakes with others, focusing on the system versus the individual, and emphasizing provider wellness. Much of the reviewed literature is limited in terms of an emergency medicine focus or even regarding physicians in general. In addition, most studies are survey- or interview-based, which limits objectivity. While additional, more objective research is needed in terms of mitigating the effects of error on physicians, this review may help provide insight and support for those who feel alone in their attempt to heal after being involved in an adverse medical event.

Conclusions: Unintentional medical error will likely always be a part of the medical system. However, by focusing on provider as well as patient health, we may be able to foster resilience in providers and improve care for patients in healthy, safe, and constructive environments.

Keywords: medical error; resiliency; second victim; wellness.

Copyright © 2017 Elsevier Inc. All rights reserved.

Publication types

• Burnout, Professional / etiology
• Burnout, Professional / psychology
• Emergency Medicine / trends
• Health Personnel / psychology*
• Health Personnel / statistics & numerical data
• Hospital Mortality
• Medical Errors / adverse effects*
• Medical Errors / statistics & numerical data
• Stress Disorders, Post-Traumatic / etiology
• Stress Disorders, Post-Traumatic / psychology

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Apologies and Medical Error

Jennifer k. robbennolt.

University of Illinois College of Law, 504 E Pennsylvania Avenue, Champaign, IL 61820 USA

One way in which physicians can respond to a medical error is to apologize. Apologies—statements that acknowledge an error and its consequences, take responsibility, and communicate regret for having caused harm—can decrease blame, decrease anger, increase trust, and improve relationships. Importantly, apologies also have the potential to decrease the risk of a medical malpractice lawsuit and can help settle claims by patients. Patients indicate they want and expect explanations and apologies after medical errors and physicians indicate they want to apologize. However, in practice, physicians tend to provide minimal information to patients after medical errors and infrequently offer complete apologies. Although fears about potential litigation are the most commonly cited barrier to apologizing after medical error, the link between litigation risk and the practice of disclosure and apology is tenuous. Other barriers might include the culture of medicine and the inherent psychological difficulties in facing one’s mistakes and apologizing for them. Despite these barriers, incorporating apology into conversations between physicians and patients can address the needs of both parties and can play a role in the effective resolution of disputes related to medical error.

Introduction

Medical errors happen [ 24 ]. When they do, they can have lasting consequences for both the patient and the physician. There is growing awareness of the ways in which disclosing such errors and other adverse events to patients can be a central part of patient care and have relevance to issues of patient safety [ 12 ]. Indeed, ethical standards articulated by the American College of Physicians and the American Medical Association oblige the disclosure of errors, the Joint Commission on the Accreditation of Hospital Organizations requires the disclosure to patients of unanticipated outcomes, and many states now require hospitals or physicians to disclose adverse events to patients [ 12 , 25 , 45 ]. Recent research suggests one central component of effective disclosure is an apology.

An apology is a statement given by one who has injured another that includes recognition of the error that has occurred, admits fault and takes responsibility, and communicates a sincere sense of regret or remorse for having caused harm [ 53 ]. At their most complete, apologies may also include promises to refrain from engaging in similar conduct in the future and compensation for the harm that has been done [ 47 ]. The messages contained in an apology can have powerful effects for both the person offering it and the recipient. In particular, apologies influence the ways in which people make judgments of responsibility—decreasing the blame that is attributed to another and decreasing the likelihood that the cause of the injury is viewed as something that is internal to and controllable by the other person [ 47 , 51 ]. Similarly, apologies influence estimates of the likelihood that the injury-producing scenario will recur; the apology is interpreted as a signal that steps will be taken to avoid similar consequences in the future [ 16 , 44 , 46 ]. Apologies also have positive effects on expectations and intentions for a future relationship between the parties [ 38 , 39 , 44 , 46 ], play a role in restoring trust [ 38 , 39 ], reduce negative emotional reactions such as anger [ 16 , 44 , 46 , 51 ], induce favorable physiological responses in both parties [ 59 ], and reduce antagonistic responses [ 16 , 42 , 44 , 46 ].

Although there has been growing interest in the role of apologies in the resolution of disputes generally [ 7 ], apologies would seem to have particular relevance to the resolution of disputes in the context of health care and medical error. The relationship between the physician and patient is one that involves considerable intimacy, vulnerability, and trust. When a patient is injured by a medical error, this relationship can be injured as well, even as patients may be in need of continuing care [ 37 ]. Incorporating apology into conversations between physicians and patients can address the needs of both patients and physicians and is consistent with the ethics of the medical profession, ethics that focus on the necessity for trust between physician and patient.

Apologies and Patients

Patients, of course, worry about bad outcomes of medical treatment, including bad outcomes that result from medical error. Patients indicate they care about understanding what has happened to them, about receiving apologies, and about preventing similar errors in the future. Witman and colleagues [ 58 ] asked patients to evaluate a number of scenarios describing medical errors from the perspective of the injured patient. Almost all the patients (98%) indicated they “desired or expected the physician’s active acknowledgement of an error. This ranged from a simple acknowledgement of the error to various forms of apology” [ 58 ]. In a similar survey, Mazor and colleagues [ 39 ] found most (88%) of the surveyed members of a healthcare plan “would want the doctor to tell [them] that he or she was sincerely sorry.”

Focus groups with patients have indicated similar preferences. Gallagher and colleagues [ 13 ] found patients desire and expect to be informed promptly about a medical error; to be given information about what occurred, why and how it occurred, how their health will be affected, and what steps will be taken to prevent future harm; and to receive an apology that signals a sense of regret and a desire to do better going forward. Indeed, they found “[m]any patients said they would be less upset if the physician disclosed the error honestly and compassionately and apologized…[and]…that explanations of the error that were incomplete or evasive would increase their distress” [ 13 ]. Patients also prefer that such communication occur without a need for prompting on their part [ 13 ].

Consistent with what patients say they would expect after a medical error, studies of patients who file suit find litigants are motivated to find out what happened and to prevent future injury, motivations that implicate apologies. For example, Vincent and colleagues [ 54 ] surveyed medical malpractice claimants about the reasons they filed suit. Over 90% of respondents indicated they wanted to prevent the same thing from happening to someone else, to receive an explanation for what had happened, or for the doctors to realize what they had done. Of the respondents who thought something could have been done to prevent the lawsuit, approximately 40% reported that if they had received an explanation and apology, they would not have felt the need to file suit [ 54 ]. Similarly, among the reasons that claimants interviewed by Hickson and colleagues [ 18 ] gave as motivating their lawsuits were the belief that “the courtroom was the only forum in which they could find out what happened from the physicians who provided care” (20%), the belief “that physicians had failed to be completely honest with them about what happened, allowed them to believe things that were not true, or intentionally misled them” (24%), and a desire to “deter subsequent malpractice by the physician and/or to seek revenge” (19%) [ 18 ]. Other studies have similarly found failure to provide explanations and poor communication generally are associated with litigation [ 1 , 19 , 21 , 34 , 35 , 48 ].

Experimental studies also provide evidence that apologies may serve to facilitate settlement of claims. For example, in several studies, Mazor and her colleagues [ 38 , 39 ] asked members of a healthcare plan to take the role of a patient and to indicate how they would respond to an injury caused by medical error. They found patients were less likely to indicate they would seek legal advice when the physician assumed responsibility for the error, apologized, and outlined steps that would be taken to prevent recurrence [ 38 , 39 ]. Similarly, Witman and colleagues [ 58 ] found patients were less likely to indicate they would file a lawsuit if they were informed of an error than if they were not informed. In addition, experimental studies in the nonmedical context have found injured persons are more likely to adopt a settlement posture that improves the prospects for settlement and more likely to accept a particular offer of settlement when they have received an apology than when they have not [ 27 , 44 , 46 ].

Apologies and Physicians

Physicians, like patients, are profoundly affected by medical errors; physicians worry about harm caused to patients; are anxious about the consequences of error for their reputations, fearing that patients and colleagues will no longer trust and respect them; experience distress, feelings of guilt, and loss of self-confidence; and are anxious about the possibility of a lawsuit [ 6 , 13 , 20 , 57 ]. Indeed, physicians describe the “sickening realization of making a bad mistake” [ 60 ] and the sense of dread on realizing that one has made an error [ 13 ].

Many physicians express the desire to apologize to patients when an error has occurred [ 13 ]. However, there is a disconnect between patients and physicians in their expectations and attitudes about the communication they will have after a medical error. In contrast to the desires and expectations of patients for disclosure and apology, there is evidence many physicians tend to provide minimal information about what happened, what led to the error, or what might be done differently in the future; to choose their words carefully so as to avoid being explicit about the error; and to believe patients who want more information will ask for it to be provided [ 13 ]. Similarly, there is evidence that providers are reluctant to make any offers of compensation for medical errors unless and until a lawsuit is filed [ 2 , 15 , 23 , 43 ].

Despite the potential benefits of apologizing, apologies are not frequently given and there is wide variation in physicians’ tendencies to offer apologies in the wake of medical error. For example, in one survey, only one-third of both physician and nonphysician respondents who had experienced a medical error in their family reported they had received an explanation or an apology for what had happened [ 3 ]. Another survey of patients who brought suit found 40% reported not receiving an explanation; in only 13% of cases did patients report responsibility for what had happened was accepted either in part or in full and in only 15% of cases did patients report receiving an apology [ 54 ].

Similarly, in a study of error disclosure by surgeons to standardized patients, the researchers found wide variation in disclosure practices [ 5 ]. Some surgeons (57%) explicitly referred to the error as an “error” or a “mistake”; others either described the event as a “complication” or “problem” (27%) or did not indicate the outcome was preventable (16%). Many, but not all, surgeons (65%) took responsibility for the error; some independently, but others only after pressed by the patient. Fewer than half of the surgeons (47%) offered some expression of apology or regret to the patient; these expressions ranged from explicit apologies for the error to much less direct statements of regret (“I’m sorry to have to tell you this…”). Very few, only 8%, assured the patient the error would be examined with an eye toward preventing harm in the future [ 5 ].

Another study examined both medical and surgical physicians’ self-reported responses to error scenarios and found physicians reported wide variation in whether they would apologize after a medical error; almost two-thirds (61%) indicated they would express regret for the adverse outcome, one-third (33%) reported they would apologize in a way that explicitly acknowledged the error, and a few (6%) would offer no apology at all [ 11 ]. The inclination to offer an apology was even smaller when the error was one that would be less apparent to the patient. Surgical specialists were considerably less likely than medical specialists to apologize [ 11 ].

Similar variation was apparent in physicians’ inclination to discuss error prevention, with most (54%) providing general assurances that future errors would be prevented, some (37%) describing in more detail what steps would be taken, and a few (9%) providing no information about prevention. Again, surgical specialists were considerably less likely to report they would discuss with patients steps that would be taken to prevent future error [ 11 ].

Barriers to Apologies After Medical Error

Perhaps the most commonly cited barrier to disclosure and apology by physicians and risk managers is fear of litigation or legal liability [ 13 , 30 ]. At the same time, however, the link between the risk of litigation and willingness to disclose has not been established. In particular, reluctance to disclose error does not appear to be correlated over time with the likelihood of litigation; “the historical evidence indicates that there was never much ex post communication with patients, even when liability risk was low” [ 22 ]. Similarly, one recent study found physicians practicing in different jurisdictions (the United States and Canada) reported a similar likelihood of having disclosed a serious error to a patient [ 14 ]. Although physicians across jurisdictions perceived differences in their chances of being sued, their beliefs about disclosure were similar [ 14 ]. Instead, variation in individual physicians’ beliefs about the relationship between disclosure and litigation was related to the likelihood of disclosure [ 11 , 14 ]. Comparisons of litigation and disclosure rates in the United States and the United Kingdom have reached similar conclusions [ 22 ].

Moreover, it is not at all clear that apologies pose the litigation risk that is often feared. First, as a general matter, empirical research has demonstrated both that most injured patients do not file lawsuits [ 23 , 43 ] and that physicians tend to substantially overestimate the risk of being sued [ 31 ]. Second, as noted previously, there is evidence that apologies tend to diminish blame and make injured patients less likely to sue and more willing to settle when they do. Third, although there has been little empirical examination of how apologies play out at trial [ 4 ], imagine the consequences of an apology for cases that still result in a trial: “The long painful, shameful spectacle of the plaintiff lawyer trying to prove in public that the physician is negligent, a bad person, will not take place. The court’s role will be limited to establishing just compensation. What is a jury likely to do with a physician who has been honest and also apologized? Judgments will most likely be far less costly” [ 33 ].

Nonetheless, in part because physicians and other potential defendants fear their apologies might be interpreted as evidence tending to prove legal liability, over two-thirds of the states have enacted evidentiary rules that make some apologies inadmissible in court as evidence of liability. Many of these statutes are limited in their application to cases of medical error, whereas other versions more broadly encompass all civil cases (which would include cases involving medical error). These statutes vary in the scope of their coverage. Some statutes make inadmissible statements that express sympathy for the others’ injuries while allowing the admission of statements that admit responsibility. Other statutes protect a wider range of statements, specifically making inadmissible statements that express “fault,” “error,” or “mistake” in addition to an expression of sympathy. A final category of statute protects “apologies” without further description [ 44 , 46 ]. Because there has been little empirical examination of such statutes, it is not clear whether or in what ways these provisions will affect the apologizing for medical error.

Beyond the threat of litigation, then, there are a variety of barriers to disclosure and apology after medical errors. Gallagher and colleagues [ 14 ] suggest “the norms, values, and practices that constitute the culture of medicine” may play a greater role in encouraging or inhibiting disclosure and apologies than does the risk of liability. In particular, a desire for and history of self-regulation and an expectation (by self, peers, and patients) of perfection may make it difficult to apologize for errors [ 55 ].

More generally, to admit that an error has occurred and to apologize for it is embarrassing and injurious to one’s pride and requires one to come to grips with a threat to one’s self-esteem. Acknowledging an error conflicts with a striving for perfection and can result in a sense of vulnerability [ 26 , 32 ]. Simply put, it is difficult to apologize. As Frenkel and Liebman [ 9 ] have noted, “Apologies have a potential for healing that is matched only by the difficulty most people have in offering them.” Indeed, physicians are reluctant to conclude that iatrogenic injury has occurred [ 56 ] and three-fourths of physicians agree that disclosing a serious medical error would be difficult to do [ 14 ].

Making a mistake that harms a patient can lead to uncomfortable feelings of cognitive dissonance; that is, it is hard to have confidence in one’s competence as a healer and to simultaneously accept that one has caused harm to another (or that the system of which one is a part has caused harm) [ 52 ]. Such feelings may be particularly difficult for physicians, because such “[d]issonance is bothersome under any circumstance, but it is most painful to people when an important element of their self-concept is threatened—typically when they do something that is inconsistent with their view of themselves” [ 52 ].

Finally, lack of certainty and skill about how to go about disclosing errors and apologizing for them may prevent many physicians from engaging in such conversations [ 11 , 22 ]. Many physicians have not been trained in how to effectively communicate with patients and, in particular, how to apologize after a medical error [ 10 ].

Effective Apologies

As noted previously, apologies have the potential to contribute to the process of addressing medical errors, in particular playing a role in disclosure conversations between the physician and the patient. However, not all apologies are created equal or are equally appropriate in all circumstances.

One of the central features of an apology—the feature that distinguishes it from other ways of accounting for harm done such as offering an excuse—is the acceptance of responsibility for having caused harm. Indeed, apologies that accept responsibility are more effective than similar expressions that simply express sympathy [ 44 , 46 ]. Sincerely offered expressions of sympathy, however, can have many of the positive effects of apologies that accept responsibility, although not to the same degree [ 44 , 46 ].

It is also the case that whether the apology is accompanied by an offer of compensation can influence its impact. The notion that appropriate compensation is relevant to apologies has been articulated by Bishop Desmond Tutu: “If you take my pen and say you are sorry, but don’t give me the pen back, nothing has happened” [ 2 ]. Adapting this notion to the medical context, Berlinger has argued, “If a physician apologizes to an injured patient, if a physician genuinely fells remorse for having injured the patient, if a physician acknowledges that the mistake was her fault, but there are no provisions for fairly compensating the patient for the cost of medical care and lost wages resulting from the injury and no provisions for helping this physician to avoid injuring other patients, nothing has happened” [ 2 ].

Finally, any apology that is extended must be sincerely offered. Sincere apologies for errors that have occurred are likely to be beneficial to both the patient and physician. However, as Miller has argued, “[w]hen victims perceive apologies to be insincere and designed simply to ‘cool them out,’ they react with more rather than less indignation” [ 40 ].

Receptivity to Apologies in the Medical Profession

Several developments over the past few years signal an increasing receptivity within the medical profession to apologizing to patients who have been injured by medical errors. First, a number of institutions have now had positive experiences with policies that entail disclosing and apologizing for medical errors. The most widely discussed example is the Veterans Affairs Medical Center in Lexington, KY. Under the hospital’s policy, medical errors are disclosed to patients (whether or not the patient was already aware of the adverse event), apologies are offered, and a settlement is offered [ 29 ]. The hospital reports that the policy has resulted in improved relationships with patients, faster settlement of claims, and decreased litigation costs [ 28 ]. The hospital also reports that although it was in the top 20% of Veterans’ Affairs hospitals in terms of the number of claims paid during the first 7 years of the policy, it was among the lowest 25% of Veterans’ Affairs hospitals with regard to total payments made to patients [ 29 ]. This suggests that although disclosure and apology may result in an increased volume of claims [ 49 ], total costs may decrease. Other hospitals (for example, University of Michigan Health System, Johns Hopkins, Children’s Healthcare of Atlanta, Boston’s Dana Farber Cancer Institute, and Massachusetts’ Sturdy Memorial Hospital) as well as private insurers (eg, COPIC) report similar experiences [ 12 , 30 , 61 ].

Two recent statements suggest a formal broadening of this receptivity. In 2006, the National Quality Forum put forward an evidence-based safe practice guideline regarding the disclosure of serious unanticipated outcomes [ 41 ]. In addition to recommending that disclosure include an explanation of what happened and the implications for the patient, a commitment to investigate, and feedback about such investigation, the guideline advises physicians to express regret to the patient when there is an adverse outcome and to apologize when there has been an error.

Similarly, the Full Disclosure Working Group of the Harvard Hospitals issued a consensus statement in 2006 that recommends caregivers “acknowledge the event, express regret, and explain what happened. If an obvious error has been made, the caregiver should admit it, take responsibility for it, apologize, and express a commitment to finding out why it occurred” [ 10 ].

Finally, some medical schools are now starting to incorporate training about error disclosure and apologies into the curriculum [ 17 , 36 ]. Such training, both for medical students and practicing physicians, has the potential to effectively teach physicians the skills necessary for effective apologies. For example, one recent study using standardized patients to explore surgeons’ disclosure skills and practices found 90% of the surgeons had no previous training in such skills, and the vast majority of them (93%) found the sessions to be a “very good or excellent educational experience” [ 5 ].

The existing research suggests incorporating apologies as part of the disclosure of medical errors can benefit both patients and caregivers. In the medical context, however, not every unfavorable outcome is the result of medical error [ 50 ]. Moreover, it may be the case that the cause of an unfavorable outcome is not immediately clear and investigation is necessary to ascertain what went wrong. Thus, the appropriate communication may differ depending on the circumstances.

For example, an apology that accepts responsibility for an error and the harm caused may be most appropriate when it is clear that an error has caused harm. This is true whether the outcome was completely or partially caused by the error and whether the error occurred at the individual or systemic level. When, however, it is clear the adverse outcome was not the result of an error, an explanation of the cause of the complication coupled with an expression of regret for the outcome and sympathy for the patient’s condition seems more appropriate.

Finally, when it is not clear what the source of the problem was, the caregiver should express regret and sympathy along with the assurance that an investigation will take place. Once that investigation has occurred, additional information should be provided to the patient along with an apology if error is discovered. Although an apology should be made relatively soon after the error occurs, an apology that is deferred until an investigation has been completed can be effective (particularly if coupled with appropriate communication along the way). Specifically, experimental studies have found apologies can be most satisfactory when the apologizer has taken the time to be able to articulate the nature of the error and its impact [ 8 ].

Of course, these distinctions may not always be completely clear. The source of an adverse outcome may be difficult to ascertain or the outcome may be multiply determined. However, in dealing with this complexity, physicians should recognize they tend to be disinclined to recognize error even when it occurs [ 56 ] and that there is a tendency to avoid directly apologizing even for clear errors [ 3 , 5 , 11 ], and consciously attempt to counter these tendencies. In any case, a patient who sustains an adverse outcome should be provided with full information about the nature of the complication, his or her injuries and prognosis, and any resulting necessary treatment.

A thorough empirical examination of the role of apologies in addressing medical error and other adverse events has only just begun. Although the existing studies, drawing on data from the field and from experimental studies, demonstrate the potential for apologies to facilitate dispute resolution in this context, there is still much we do not know. In particular, future research might examine physician decisions about whether and how to apologize; the effects of training about communication, disclosure, and apologies on physician apology and how such formal training interacts with the informal training physicians receive; and the effects of evidentiary rules on physician decisions to apologize.

Sincere apologies offered in the wake of a medical error may lead to a lessening of suffering for both patients and physicians in coping with the error and its consequences, contribute to improved relationships between physicians and patients such that these relationships are able to continue, and reduce costs by preventing lawsuits and facilitate the settlement of valid claims. Continuing empirical examination of the complexities of apologies in the context of medical error is a positive step and is likely to be a valuable contribution to the discussion.

Acknowledgments

I thank David Hyman for his helpful comments on a previous version of this article.

The author certifies that she has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.

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Medical Errors, Essay Example

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The literature that has been published on the topic of medical errors in health care present evidence indicating that there is a low level of awareness concerning this problem. Typically, medical errors are handled internally and it often becomes the responsibility of health care professionals to determine how these will be resolved and prevented. While national and local laws that are put in place to guide medical practice provide information that helps health care institutions understand the level of quality that is required, there is little support from these agencies in terms of actual implementation. As a consequence, medical errors are seen to be the responsibility of individual hospitals and employees and they are therefore silenced in the public domain.

There are many medical errors because practice standards have not evolved in a manner that is conducive to prevention. Many modern hospitals are dealing with budgetary crises that forces the administration to focus on determining how to work with limited resources rather than heightening safety standards. Furthermore, even when quality improvement initiatives are put in place, it is often challenging to establish suitable training programs that will ensure full compliance from staff due to a lack of time and resources available. Health care systems can report, monitor, and prevent medical errors from happening more substantially if health records are recorded on electronic health record systems and regularly accessed by each employee working with the same patient. This will allow them to gain a greater understanding of the initial interview and which medications have been prescribed, along with a wealth of other related information. Furthermore, this provides employees with the potential to communicate with one another more significantly, which makes a big difference to prevent medical errors that occur as a consequence of shift changes. Ultimately, switching records to a digital means will allow protocol to be checked which will help prevent against commonly made mistakes.

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Patient Safety and Medical Errors Reduction Essay (Critical Writing)

Introduction, the distinction of errors and adverse events, accountability and policy, approaches to minimize errors, response toward medical errors and patient safety.

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The twentieth-century medical sector has been criticized for the lack of a stable patient’s safety policy and inabilities to create the systems under which healthcare is properly provided. Insurance companies have to take responsibility for any errors that occur in the healthcare system, still, these companies do not find it necessary to elaborate on the challenges even because its vast majority aims are reducing patients’ claims and necessities.

Every day numerous preventable events occur in the medical field that could be easily avoided in case proper regulation and enforcement of patient safety are considered. The point is even though some regulations are provided, not enough information is used to prove the idea that these regulations may considerably improve patient safety. 1 Several attempts made by media reports as well as the various interested parties such as insurance companies have resulted in the formulation of a range of policy proposals that aim at providing an amicable solution to the question of patient safety.

The complexity and bureaucracy that comes with medical systems take up the greater share of the blame, and healthcare systems choose to allow the various organizations to device their mechanisms of dealing with the problem. The purpose of this paper is to prove that several alternatives may be used to elaborate medical errors, promote the improvement of medical healthcare under a variety of conditions, and stop blaming individuals for making mistakes that are not always based on personal poor knowledge or experience.

The current statistical data in the US indicates that tens of thousands of American people die annually because of preventable medical errors. 2 This fact falls in the range of other causes of death such as road accidents and breast cancer. Still, the statistics omit some unreported deaths caused by medical harms as well as those which are reported as serious still not as fatal. 3

It is common knowledge that the healthcare sector has remained a step behind the trend in all other sectors in as far as industrial safety is concerned. Several investigations have been conducted to define the connection that takes place between the already existing systems and the number of errors that lead to unpleasant results in medical practice. The researchers such as Runciman and his team, Watcher, and Vincent introduce different points of view and develop their ideas on the fact that it is wrong to blame one person in case of incompetence or negligent performance.

There is a need to distinguish between errors and adverse events. It is possible to admit that the error differs from the adverse event by the fact that the error occurs by an act or omission whose consequences are the undesired outcome. 4 And the injuries which are usually caused by medical management or misacts are usually defined as adverse events. 5

According to Wachter, some people may argue that there is no difference between medical errors and adverse events since the parties end up suffering in either case. However, this argument lacks weight since the distinction between these terms helps us in identifying the party on whom the burden is to be placed. 6 The prevention and management of these events require the engagement of better scientific methods that do more than reform how things are done. The reform of these systems and procedures will be motivated to a great extent by the ethical and professional considerations and standards. It would be an empty attempt to administer a policy that is directed to prevent the errors and be ready to take the actions which are safe for patients as well as for the medical staff.

Vincent offers a captivating and rather effective policy in his research that is based on record reviews. What is offered is the definition of several stages that have to be taken by nurses. The first sage is all about the identification of the records which may be helpful in the investigations. Watcher also attempts to gather and evaluate different medical errors to educate the staff and help doctors define their activities. The next stage should encourage doctors to analyze the records and learn about the mistakes and misunderstandings dated earlier.

Finally, it is not always required to compare the current challenges with those which came from the past. This is why even Runciman and his team of researchers admit that the classification of the adverse events will help to improve considerably medical treatment and correspondence to all ethical and professional standards which are required. 7

Technological and ideological advancement in the 20 th century has played a tremendous role in motivating the study of medical error and patient harm. Historically, the problem has been neglected and given little if any attention. 8 This outlook has changed especially in the last ten years that have seen the medical error debate take a political twist into the professional and public arena. Oblivious to the fact that there were millions of people suffering under the harm of medical errors the medical institution continued to ignore this aspect.

Unfortunately, the focus has been on medical errors rather than the methods or the system that may reduce such events. Furthermore, Runciman claims that the focus sometimes was on blaming the individual as the error was considered to be a moral failure, 9 which left both the physician and the patient feeling accountable and unsafe. Thus, in general, anyone working in a system that has not set safety as one of its major priorities may fall under the medical error and be blamed.

Traditionally the burden of medical errors was placed on physicians and nurses since they were the actual people on the ground involved with the treatment care and operation of the patients; however, their cooperation with the representatives of management department is not as successful as it might be, this is several misunderstandings and errors take place. 10

In a general sense, accountability may push many nurses and physicians to the assumption of responsibility for actions and omissions committed. 11 After an error takes place, it is necessary not only to take responsibility but also be able to inform the patient and family, apologize, and explain what actions may be taken to prevent some problems in the nearest future. 12 The author argues that physicians are prone to trouble regardless of their education and training. Thus, the focus should move from blaming an individual toward patient safety. 13

For instance, the early 1960s physician was supposed to master at least 15 different medications that were necessary for the treatment of common illnesses of the time. Still, such an attempt cannot be properly justified as this individual error did take place, and even sufficient education and training were not enough to overcome the error and make use of the knowledge gained. This is why it is hard to define the quality medical backgrounds in case some errors take place.

The medical practice has since grown to thanks to technology and research. As a result, there has been also an increase in the number of medication errors that have risen to over 12% of the whole reports. 14 It would, therefore, be unreasonable to imagine that the modern-day physician will be able to memorize and utilize that information when required. The advancement has brought about new challenges as well as increased risk of medical errors.

The justification for the adoption of these technologies has been that there is a better chance that the machines will make fewer errors compared to humans. 15 It is the probability of error in a human being; this is why it is much more relative than that of the machines. Machines are not able to take care of the environment or to promote the required safety to patients, and it is to decide whether such participation of the machines may be justified.

Even so, the thought of an entirely safe environment for the treatment of patients is a farfetched fallacy, 16 since there are many other variables involved in the treatment process. In general, the machines cannot function without individual management and therefore the chances of a slip or miscalculation still do exist. 17 Consequently, a machine will keep on with its function regardless of the surrounding effect, while a human will see what is going on and will base on that they will modify their actions.

The advancement in technology offers a conveniently delicate chance for hedging against and prevention of medical errors. Machines require due diligence and care since a simple slip could cause grievous harm or even death. Therefore, it means that the human element should be carefully examined in the formulation and adjustment of the system of error management. Several policies may be implemented in the system to control the outcomes which are not always easy to predict under some particular conditions.

First of all, it is very important to report any medical errors and work on avoiding similar future mistakes that may affect the safety of the patient or weaken the organization’s performance and reputation. And second, it is beneficial to promote a policy using which management of errors will be easier and will correspond to standards set by society. The example of a successful policy is introduced by Vincent. He discusses the achievements of Jeffrey Cooper with the help of whose achievements the work of anesthetic machines has been considerably improved.

Through thorough observations, the researcher proved that several adverse events and errors may be controlled in case more attention is paid to the way of how the operation is managed each time. 18 Such a policy helps to regulate the behavior and sets standards that should be met by the practitioners as it will create a benchmark for the medical practice upon which records of compliance may be taken.

It also allows for the creation of an oversight body that regulates and controls the activities of the different participants, this is why the author justifies it from a variety of aspects. Another powerful contribution offered by Wachter is the justification of the Human Factors Engineering (HFE) as one of the techniques that can be used to improve the system performance and reduce errors. 19 This model emphasizes the device design and the use of it such as catheters, computers, etc.

The last ten years have conclusively altered the traditional approach from the individualized approach that seeks to place the blame on the individual to an ethical campaign that seeks to ensure that people are more careful. The change has been motivated by two main aspects. First, the traditional approach ignores the fact that the errors are committed by hardworking and well-trained individuals who have been tried and tested for the performance of these activities.

It, therefore, acted to discourage the practitioners and limit the exploratory ability of the participants in the field of medicine. Secondly, the medical field is inadvertently a victim of the inevitable human error. It is within human scope to make mistakes and the medical field is of no exception; unfortunately, the mistakes made in this field are much more crucial for human lives in comparison to the mistakes made in other fields. The extent of safety is no longer a matter of individual care but more of the ability of a system to predict and manage an error. 20 This proactive approach had been successfully implemented in other industrial sectors such as the nuclear and aviation sectors.

It also embodied an investigation and analysis of the trend presented by dozens of accidents in non-healthcare fields such as aerospace and transport fields. The prevention model helps to define the conditions under which an organization with a complex system of management sets its requirements and the participants of the system such as doctors and nurses have to evaluate the occurrence of errors by themselves. 21 Before the occurrence of these errors, a person has to penetrate a host of system checks that regulate chances of occurrence of a tragedy or error. 22

In effect, the model suggests that it is not a question of perfecting the human act but more of the reduction of an opportunity for the engagement on the human in risky behavior. Sometimes, it seems to be enough to identify possible errors and try to do everything to avoid the problems. Still, even professional medical staff is not always ready to make use of their experience and achieve the best results. This is why the offered model concerning the prevention of errors may be integrated into a variety of ways considering the requirements set by a particular case.

One of the most common ways to minimize errors that have been conducted worldwide is the “double checks”; to ensure that some procedures are performed correctly, such as blood administration; it has to be double-checked by nurses before transfusion takes place. And now the majority of hospitals are using these techniques for other high-risk medication. The regulations, accreditation standards and laws have an important role in ensuring patient safety, as they make obligatory following the right instrument on the right job. They are powerful tools to promote patient safety in that they can mandate certain practices.

For instance, in the case of the pilot who landed successfully on the Hudson River, when he was asked how he did it, he replied: “I put my hand on the side stick and I said, the protocol for the transfer of control, my aircraft, and the first officer answered your aircraft”. The meaning here is that having a strong protocol and standards for patient safety will help in rescuing the patients and the providers from falling into such medical errors.

In response to the concerns of errors and patient safety, Wachter suggests utilizing the “Swiss Cheese Model” to analyze the errors and minimize it. 23 In some events, this model has been proved to help on locating the source and the cause of the error and make it foreseeable. Thus, from that point, providers can implement multiple courses of protection to diminish the cause of such errors. For example, respect and assure meeting patients’ preference regarding resuscitation, or guaranteeing that the operation will be done on the correct limbs.

In contrast, on Safety and Ethics in Healthcare , Runciman argues on the efficiency of applying the “Swiss Cheese Model” with some hospital departments. For example, using the multiple tests and verifications to ensure that the patient has received the right medication and eliminate the infection of the wrong medication might be practical in some departments, and might not be for other departments such as the emergency department. Because of the higher demand and the time consuming, the patient might die from an infection while the providers are still navigating steps. 24

Another side effect is that busy physicians and nurses might disregard the required steps to focus on their patients. 25 However, the “Swiss Cheese Model” might be practical at the beginning of the discussion and eventually become unworkable on when to render the clinical service. The peculiar feature of the chosen model is the possibility to control the errors and do not provide them with a chance to spread into the system. The author perfectly compares it with the holes in the cheese. It is hard to find a slice with the holes which are at the same place. The same happens with the errors. They do not happen at one place several times, this is why the medical staff has to be ready to identify the error, try to prevent it if possible, and evaluate its effects on patient safety and care.

The perplexity embraces the continued lack of a comprehensive ethically motivated mechanism for the management of and the improvement of the safety conditions in the healthcare system. Even though there is a great deal of information that has been documented regarding the role of systems in the increased number of medical errors, policymakers are not keen to confront the problem as it is. The point is that medical errors are usually inevitable; they are inherent to the system, this is why it is not always rational to fight against them.

Of course, the easiest way is to blame a person and make his/her take responsibility for the errors. Still, the healthcare system has to be based on properly chosen strategies and ideas, this is why it is better to focus on different models like the Swiss Cheese Model or any other defined in the paper. Though one of the main principles in healthcare is to not harm patients, several debates still take place. The principle of non-malfeasance stretches the obligatory net to accommodate errors of commission such as incorrect drug prescriptions, careless surgical slips, administration of drugs to the wrong patient and misstatements in the entry of records.

Even though the errors that occur can be limned to the individual in person the professionalism concept of ethics indicates that the patient is the primary object of safety. Safety from an ethical point may also be justified by the utility concept. The utility principle recommends maximum benefit for the greatest number of people. The public policy aims at ensuring the general safety of the public. Public health ethics demand that the policies adopted should in as far as possible execute safety improvements. Therefore, it is more effective to identify errors and implement systems that prevent care providers from committing such errors instead of searching for a person to be blamed.

Runciman, Bill, Merry, Alan, Walton, Merrilyn. Safety and Ethics in Healthcare. Hampshire: Ashgate, 2007.

Vincent, Charles. Patient Safety , West Sussex: Willey-Blackwell, 2010.

Wachter, Robert, M. Understanding Patient Safety . New York: McGraw-Hill Companies, 2008.

• Wachter, Robert, M, Understanding Patients Safety (New York: McGraw-Hill Companies, 2008), 183.
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• Vincent, Charles, Patient Safety , (West Sussex: Willey-Blackwell, 2010), 52.
• Vincent, 53.
• Runciman et al., 39.
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• Wachter, 232.
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• Runciman et al, 95.
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• Wachter, 22.
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• Chicago (A-D)
• Chicago (N-B)

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