Medical Errors II, the Aftermath: Mea Culpa!

By Swaminath, G.; Raguram, R. | Indian Journal of Psychiatry, January-March 2011 | Go to article overview

Medical Errors II, the Aftermath: Mea Culpa!


Swaminath, G., Raguram, R., Indian Journal of Psychiatry


Byline: G. Swaminath, R. Raguram

"Mistakes are a fact of life. It's the response to the error that counts".

- Nikki Giovanni (American poet, 1943)

Alexander Pope's famous words, "To err is human, to forgive divine", apt in most situations do not seem quite appropriate while dealing with medical errors. Forgiveness suggests that there has been the committing of sin, and this is inextricably linked to fault and blame. [sup][1]

Patient safety traverses all medical specialties and affects every health-care professional. The attention to medical errors and adverse events and the resultant literature have grown exponentially over the past decade. A number of practicing physicians, however, remain unaware of the extent of the problem, the impact on patients, and the burden on the health-care system. Many are unfamiliar with strategies to reduce the risk of harm. [sup][2]

When patients suffer harm, most providers of healthcare are ill prepared to respond. Abandonment of care providers and patients is common. [sup][3] The tendency to "shame and blame" often perpetuates the "wall of silence" [sup][4] between providers and patients. [sup][5]

It was in response to this unsatisfactory situation that the "Patient Safety Movement" was founded, guided by the nonjudgmental recognition of the ubiquity of human and system errors. By understanding that error-particularly human error-is inevitable but still largely preventable, patient safety efforts focus on improving systems, creating fail-safe mechanisms that intercept error before it reaches the bedside, and on implementing measures that mitigate harm when an error involves the patient. [sup][1]

Explanatory Models of Human Error

There are two explanatory models of causation of human error: the person approach and the system approach. The person approach focuses on the errors of individuals, and is apt to accuse them of forgetfulness, inattention or moral failure. Followers of these approaches tend to treat errors as moral issues, assuming that bad things happen to bad people-what psychologists have called the "just-world hypothesis". [sup][6]

The basic premise in the system approach is that humans are fallible, and errors are to be expected, even in the best organizations. Errors are seen as consequences rather than causes. These include recurrent error traps in the workplace and the organizational processes that give rise to them. The system approach identifies the conditions and systems under which individuals work, as the source of the error, with the aim of both understanding the origins of error and building defenses to avert errors or to mitigate their effects. [sup][6]

The system approach acknowledges that the majority of clinical errors do not result from individual recklessness or the actions of a particular group. [sup][7] The most common systems deficiencies identified as underlying clinical errors are failures in dissemination of drug knowledge or its updating, and inadequate availability of patient information such as test results necessary for safe treatment. [sup][8]

Detection of Medical Errors and Adverse Events

Difficulty in identifying medical errors and adverse events creates a significant barrier to assessing risk reduction strategies. In the absence of an accurate, reliable methodology to measure errors and events, the ability to assess the impact of patient safety initiatives remains challenging.

Historically, identification of medical errors and adverse events relied on incident reports, a methodology that has many pitfalls. If an error or adverse event is identified, staff may assume, mistakenly, that someone else will report it. Personnel who do report events often receive no feedback, which serves as a disincentive for reporting subsequent events. [sup][2] Staff may have valid apprehensions about reporting errors and adverse events. [sup][2] There is a natural hesitancy to point out one's own mistakes for fear of being labeled incompetent and a reluctance to point out others' mistakes for fear of being labeled a whistleblower, [sup][2] a sensationalist or an adversarial professional. …

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