Medical Errors: Back to the Basics

Rahul K. Shah, MD, George Washington University School of Medicine, Children’s National Medical Center, Washington, DC I was fortunate to be able to give a course at our recent annual meeting on errors in otolaryngology. The participants were engaged and I hope learned a little bit about the zones of risk in our practices with errors in otolaryngology. The course began with clarification on the definitions of medical error, adverse events, and near misses. Upon reflection, I determined it would be an opportune time to take a step back from our regular monthly column where we highlight innovative and cutting-edge concepts, programs, etc., with regard to patient safety and medical quality and to instead provide examples on the issue of medical errors. There are myriad definitions of medical error and one can possibly find such that support their viewpoints or their perspectives. I have spent several hours trying to find the perfect definition of medical error. Suffice it to say, there are nuances in many of the definitions. Rather than argue about the precise definitions of medical errors, I will list some examples of situations that may help explain when an event is classified as a medical error, adverse event, or near miss. A commonly accepted definition of medical error is that something occurred that was unintended or was improperly executed. For example, a resident and attending discuss a patient and decide to obtain central access for a critically ill ICU patient. The resident prepares the patient for an attempted internal jugular venous access and after much effort, converts to a subclavian line. There is no error inherent in this decision-making process as the patient needed venous access and was presumably consented for such. The patient with the subclavian line then develops a blood stream infection, perhaps a central-line blood stream infection (CLBSI). This would trigger reporting in many hospitals and would certainly be a metric that the intensive care unit tracks. This is not a medical error, per se, rather an adverse event. An adverse event can be considered an event that occurs as a result of the treatment of the underlying medical condition. A great example is a patient correctly diagnosed with an acute otitis media and  placed on the correct antibiotic, who develops a severe rash necessitating hospitalization and close wound care as a result of the antibiotic. This patient had an adverse event in that the underlying medical treatment resulted in his hospitalization. Similarly, the CLBSI in the previous example is not a medical error, unless the patient was not prepared in a sterile fashion, sterile techniques were not used, post-operative wound care was not the standard, etc. Hence, what seemingly appears to be an adverse event may, upon very close inspection, actually be a medical error. Complicating the situation even more is that the error may be a latent defect in the system—the reason a cohort of patients are having CLBSI may not be related to the institution, but perhaps to the manner in which the company industrial plant sterilized the central line, and so on. You can see how exhausting if not impossible the exercise is in determining the accountable step in such a scenario. Hence the applications of systems-science and continuous quality improvement to approach the outcome of interest in a systematic manner. To build on our rather simplistic example above, a near miss would have been if the attending and the resident discussed that patient Mr. Y needed central access and the resident went into the room of Mr. Z and began prepping the patient and setting up the central access kit. He was caught by the nurse, who told the resident that Mr. Z did not need central access per morning rounds/report and the resident then realized his mistake. Note that the error never reached the patient and there was no harm. Therefore, this would be considered a near miss. As you can see from the above examples, the distinctions between these groups are crystal clear. Actually, not at all! There are many shades of gray when categorizing incidents in hospital settings. Many institutions have super-committees consisting of senior-level executives, risk managers, quality improvement staff, etc., that help adjudicate and decide on the severity of events and the proper classification for such. One can imagine that these classifications not only affect the perceived quality of the hospital, but also significantly affect the liability premiums for the organization. I hope these examples demonstrate how a simple classification scheme can be quite complex when trying to operationalize.  Members of the Patient Safety and Quality Improvement Committee, Academy staff, and I will be more than happy to discuss with Academy members the examples above and the nuances of the definitions. Please do not hesitate to reach out to us for such clarification and discussion. We encourage members to write us with any topic of interest, and we will try to research and discuss the issue. Members’ names are published only after they have been contacted directly by Academy staff and have given consent to the use of their names. Please email the Academy at qualityimprovement@entnet.org to engage us in a patient safety and quality discussion that is pertinent to your practice.