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Editorials
Medical errors: a common problem
It is time to get serious about them
and
an implicit conclusion that they are getting more common. What is
the truth? Firstly, errors have always happened. Secondly, there has
been no clear indication as to how common they are in the United
Kingdomthough
a pilot study in this week's issue represents a first attempt to
quantify the size of the problem (p 517).1
Alongside this is the difficulty of indicating risk. To a bereaved
relative the knowledge that there was a 1 in 1000 risk is
no consolationfor
them it was 1 in 1. In a country where millions are spent every
week on the national lottery the concept of risk is obviously alien.
What is clear, however, is both that we need to know more about
errors and to do more about them.
How common are errors? Can they be minimised? And how should we tackle risk
management? One problem in assessing the frequency of errors is that
we are deeply immersed in a blame culture, so it is hard to persuade
people to report them. Many errors do not cause harm, but in many
ways these are as important as those that do. They indicate a
breakdown in the system or a wrong decision. If we are to learn from
mistakes then we need to know about as many as possible so that
corrective action can be taken. This requires a cultural change and
sensitive handling of the individual making the report. A recent
report from Chesterfield has shown a 150% increase in error
reporting by threats of disciplinary actionapparently
effective but perhaps not the best approach.2
Few reliable studies of adverse events exist. Two seminal studies were
reported some years ago from the United States 3 4 and
Australia5
showing adverse event rates of 3.7% and 16.6% of admissions
respectively, with intermediate rates in Colorado and Utah. 6 7 In the
Colorado study rates were higher in the elderly.8
Problems arise because of definitions; and retrospective analysis
can be subjective. What appeared to be clinically reasonable at the
time may be second guessed if an adverse event occurs. Nevertheless,
a figure of 5-10% is worrying, particularly since a half or more of
these events were deemed preventable.8 Similar
rates were found for interpreting emergency radiographs.9
Finally, we now have some British data from London based on retrospective
record review. In their study of over 1000 records in two acute
hospitals, Vincent et al found that almost 11% of patients
experienced an adverse event, over half of which were deemed
preventable judged by ordinary standards of care.1 More
worryingly, at least a third of these events led to disability or
death. This was a pilot study but there is no reason to believe that
the results are unrepresentative. The frightening extrapolation of
these data suggests that in England and Wales adverse events lead to
an extra 3 million bed days at a minimum cost of £1bn per year.
Only a full scale study can substantiate this estimate, and if the
NHS is serious about learning about and reducing errors it should
fund such a study.
What can be done about these errors? They cannot be ignored. Once errors are
recognised their causes must be analysed so that preventive measures
can be applied. Some of the mistakes are caused by systems failuresthis
has been shown, for example, with drug errors or wrong transfusions.
Clear definition of clinical responsibilities is needed. Fatigue may
also cause problems, as does the use of inappropriately junior
staff. The main causes of adverse events relate to operative errors,
drugs, medical procedures, and diagnosis. Each of these is amenable
to prevention. Better surgical training is obvious. This has been
taken on board by the Royal College of Surgeons, though concerns
remain that, because of shorter training and tighter working hours,
young surgeons are less experienced than previously. Better training
programmes will also help with medical procedures. Fewer operations
and procedures during the night may also help. Drug errors remain a
problemno
one can remember all the possible drug interactions that may occur,
and incorrect dosages are also a recurrent problem. A computer
linked pharmacology system, such as that described from Birmingham,10
seems an ideal preventive and learning tool. This system sends
warnings when incompatible or otherwise dangerous drugs are
prescribed, and the introduction of such a system nationwide could
prevent hundreds, indeed thousands, of errors. Errors in diagnosis
could be minimised by better training and wider use of protocols and
diagnostic algorithms.
Errors are problems that will not go away. A pilot study by the Royal
College of Physicians into deaths after admission for medical
emergencies suggests that some error occurred in as many as one in
five cases, although not necessarily leading to an adverse event
(unpublished). These data should be interpreted cautiously but do
suggest that actual recorded adverse events are the tip of the
iceberg. Analogies are often drawn with airline pilots. These are
overinterpreted in that an aeroplane should behave predictably on
all occasions, whereas every patient is different and the same disease
can present in myriad ways. Nevertheless, we can learn from the
airlines, as David Johnson suggests on p 563.11 They
spend a much higher proportion of revenue on training and they report
all incidents, with "blame" being minimised. This is a habit
which we should adopt, but it requires a much more sympathetic approach
from management than has pertained in the past.
Even more important, we need, as suggested by Vincent et al1 and
England's chief medical officer12 to
put in place a national system for recording adverse events. This is
an enormous undertaking and could be introduced initially in high
risk areasbut
in the end it should be a matter of course in every medical setting,
public and private, in the United Kingdom. Only then will we really learn
and improve our practice to the ultimate benefit of the public.
K G M M Alberti
Royal College of Physicians of London, London
NW1 4LE
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1. |
Vincent C, Neale G, Woloshynowych M. Adverse events in
Bristol hospitals: preliminary retrospective record review. BMJ 2001;
322: 517-519 |
|
2. |
Hospital staff made to expose mistakes. Sunday Mirror
2001; 18 Feb. |
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3. |
Brennan TA, Leape LL, Laird NM, Herbert L, Localio AR,
Lawthers AG, et al. Incidence of adverse events and negligence in
hospitalised patients. Results of the Harvard medical practice study I. New
Engl J Med 1991; 324: 370-376 |
|
4. |
Leape LL, Brennan TA, Laird NM, Lawthers AG, Localio AR,
Barnes BA, et al. The nature of adverse events in hospitalised patients.
Results of the Harvard medical practice study II. New Engl J Med 1991;
324: 377-384 |
|
5. |
Wilson RM, Runciman WB, Gibberd RW, Harrison BT, Newby L,
Hamilton JD. The quality in Australia healthcare study. Med J Aust
1995; 163: 458-471 |
|
6. |
Thames EJ, Studdent JM, Burstin HR, Orav EJ, Zeena T,
William EJ, et al. Incidence and types of adverse events and negligent care
in Utah and Colorado in 1992. Med Care 2001 (in press). |
|
7. |
Gawande AA, Thomas EJ, Zinner MJ, Brennan TA. The
incidence and nature of surgical adverse events in Colorado and Utah in
1992. Surgery 1999; 126:-75. |
|
8. |
Thomas EJ, Brennan TA. Incidence and types of preventable
adverse events in elderly patients: population based review of medical
records. BMJ 2000; 320: 741-745 |
|
9. |
Espinosa JA, Nolan TW. Reducing errors made by emergency
physicians in interpreting radiographs: longitudinal study. BMJ 2000;
320: 737-740 |
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10. |
Nightingale PG, Adu D, Richards NT, Peters M.
Implementation of role based computerised bedside prescribing and
administration: intervention study. BMJ 2000; 320: 750-753 |
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11. |
Johnson D. How the Atlantic barons learnt teamwork. BMJ
2001; 322: 563 |
|
12. |
Department of Health. An organisation with a memory:
report of an expert group on learning from adverse events in the NHS.
London: DoH, 2000. |
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This
article has been cited by other articles:
- Gough, M H, Buss, P., Wilson,
T., Turton, C., Nottingham, J., Rubin, G., Horton, R., Maran, N. J,
Glavin, R. J, Grunewald, R. A, Mack, C. J, Root, T., Stefanou, A.,
Siderov, J., de Lemos, M., Langford, N J, Martin, U, Kendall, M J, Ferner,
R E, Smith, N., Burns-Cox, N., Solomon, L., Holmes, S. (2001). Medical
errors. BMJ 322: 1421-1421
[Full text]
Rapid Response responses to this article:
Read all Rapid
Response responses
Electronic patient records - the begining of
recording & preventing error
Dr Robert Varnam, GP & Clinical
Research Fellow , School of Primary Care, University of Manchester
bmj.com, 2 Mar 2001 [Response]
The uses of error
richard horton, editor, the lancet
bmj.com, 2 Mar 2001 [Response]
Practical Immediate Action for Adverse Events
Assoc. Peof. Leslie Reti, Chair,
Adverse Event Review Panel , Royal Women's Hospital, Melbourne
bmj.com, 2 Mar 2001 [Response]
common problem but the main reason?
Dr Vasantha Kumar, Consultant
Physician/ Clinical Director (Medicine) , Milton Keynes Hospital
bmj.com, 3 Mar 2001 [Response]
Packaging of drugs-a disaster waiting to happen
David Shlugman, Consultant
Anaesthetist , Radcliffe Infirmary, Oxford
bmj.com, 4 Mar 2001 [Response]
Iatrogenics in France
Renato Barrios, medical resident
bmj.com, 4 Mar 2001 [Response]
Giving injections safely - read the label out loud
Dr Mary B Taylor, G P Principal , Aboyne,
Aberdeenshire
bmj.com, 4 Mar 2001 [Response]
The ethos is important
Paul Buss, Consultant Paediatrician
, Royal Gwent Hospital
bmj.com, 5 Mar 2001 [Response]
"Knowing is not enough; we must apply. Willing
is not enough; we must do."
Dr Tim Wilson, 2000/1 Harkness
fellow , Mill Stream Surgery, Benson
bmj.com, 5 Mar 2001 [Response]
The Necessity of Error
William P. Gruzenski MD, Chief of
Clinical Services , Clarks Summit State Hospital, PA, USA
bmj.com, 5 Mar 2001 [Response]
Iatrogeny
J. Calinas-Correia, medical
practitioner , Cornwall
bmj.com, 6 Mar 2001 [Response]
Terminology of error is important
Greg Rubin, Professor of Primary
Care , University of Sunderland
bmj.com, 7 Mar 2001 [Response]
Re: Iatrogeny
ian nesbitt, spr anaesthesia , newcastle
bmj.com, 7 Mar 2001 [Response]
think again! read for your wellbeing!.
gurdeep singh pannu., medical
officer. , queen elizabeth hospital,kota kinabalu,sabah,malaysia.
bmj.com, 8 Mar 2001 [Response]
Medical errors- how do we reduce them
Mr U I Esen, Consultant
Obstetrician & Gynaecologist , South Tyneside Healthcare Trust
bmj.com, 9 Mar 2001 [Response]
Crisis Avoidance and Resource Management Courses for
Doctors
Nicola J Maran FRCA & Ronnie J
Glavin MPhil, FRCA, Educational Co-directors, Scottish Clincial Simulation
Centre , Scottish Clinical Simulation Centre, Stirling Royal Infirmary,
Stirling FK8 2AU
bmj.com, 9 Mar 2001 [Response]
Taking the 'medical' out of 'medical' errors
Stavros Prineas, consultant
anaesthetist , Dubbo Base Hospital NSW Australia
bmj.com, 10 Mar 2001 [Response]
Medical errors - the primary care perspective
W F Cunningham, GP & Clinical
governance Lead West Northumberland PCG , The Tower, Hexham, Northumberland
bmj.com, 7 Apr 2001 [Response]
Medical Errors - a response
Dr Bill Ryder, Consultant
Anaesthetist , Queen Elizabeth Hospital, Gateshead
bmj.com, 9 Apr 2001 [Response]
Related letters in BMJ:
Not again!
Philip J Bickford Smith, J R C
Seale, Saad M B Rassam, Tim Wilson, Anmol Malhotra, Mathew Matson, Otto Chan,
and Roger M Goss
BMJ 2001 322: 548. [Letter]
Medical errors
M H Gough, Paul Buss, Tim Wilson,
Charles Turton, John Nottingham, Greg Rubin, Richard Horton, Nicola J Maran,
Ronnie J Glavin, Richard A Grünewald, Carina J Mack, Tim Root, Angela Stefanou,
Jim Siderov, Mario de Lemos, N J Langford, U Martin, M J Kendall, R E Ferner,
Natalie Smith, Nick Burns-Cox, Lemke Solomon, and Simon Holmes
BMJ 2001 322: 1421. [Letter]
Other related articles in BMJ:
EDITOR'S CHOICE
Medical error: creeping from words to action.
BMJ 2001 322: 0.
EDITOR'S CHOICE [GP]
Medical error: creeping from words to action.
BMJ 2001 322: 0.
PAPERS
Adverse events in British hospitals: preliminary retrospective record
review.
Charles Vincent, Graham Neale, and
Maria Woloshynowych
BMJ 2001 322: 517-519.
PRESS
Press: Blunders will never cease • How the media report medical errors • A risky business.
Trevor Jackson and Alison Harper
BMJ 2001 322: 562.
PERSONAL VIEWS
How the Atlantic barons learnt teamwork.
David Johnson
BMJ 2001 322: 563.
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