Medical error

Difficult and often dramatized, the subject of medical error was once again in the spotlight thanks to the 2000 report To Err is Human: Building a Safer Health System from the US Institute of Medicine.

The international literature on medical error is extensive. A recent search of the MEDLINE database found that 6000 of 35 000 journal articles published in the past 5 years were focused on this topic.

In the US, the Institute of Medicine report provides an excellent overview of the nature and magnitude of the problem. The Institute published a second report in 2001, Crossing the Quality Chasm: A New Health System for the 21st Century, that described means of addressing the problem through system changes. The focus shifts, somewhat, from error prevention to quality improvement.

In the UK, the 1999 report from the Department of Health, Supporting Doctors, Protecting Patients, addressed poor performance of physicians rather than errors specifically (see www.doh.gov.uk/cmoconsult1.htm).

In Canada, notable is BC coroner Susan McIver’s recent book, Medical Nightmares: The Human Faces of Errors, discussing 33 cases involving errors. Phillip Hébert’s article[1] on the ethics of disclosure of error provides a succinct summary. The ethics, law, and policy of disclosure are covered together with more general reviews of research studies and lists of key organizations and web links.

It is agreed that more research is needed. As a result of the Institute of Medicine report, in 2001, the US Agency for Healthcare Research and Quality (AHRQ) awarded US$50 million in research funding (see www.ahrq.gov/qual/errorsix.htm). In Canada, the Canadian Institute for Health Information and the Canadian Institutes for Health Research are undertaking a research study to determine if medical error is as common in Canada as it is in the US, with a report expected in 2004.[2]

Other solutions are being developed. Medication errors have been studied most, with electronic reminder systems showing the most success. Some argue for a focus on medical injury rather than medical error.[3] Sunnybrook and Women’s College Health Sciences Centre address the problem with the establishment of an Error Management Unit.4 The College of Physicians and Surgeons of Alberta recommends that the Alberta government create a provincial agency for patient safety.[4]

Better access to information does not always result in better quality of care. Montreal physicians give a case report of an infant with diarrhea complicated by inaccurate advice given by an emergency room physician and corroborated via the Internet.[5] These authors note that there are no other reports of harm caused to children by information gathered from the Internet.

What effect does error have on physicians? The Lancet column, “Uses of error” provides a forum to disclose errors made and how they were dealt with. The writers report from wide ranges of practices, rural and urban, general and specialist, and from throughout the world. A significant number generate changes in how similar cases are handled. Some follow up with research studies—one even a research career—and educational activities to ensure that the errors reported are not repeated by others. Common themes are the need for skepticism, humility, thoroughness, and patient communication. Many are near misses, with no adverse effect, except to the physician’s confidence and self-esteem, and the catharsis of writing the column is often apparent. College Library staff know that the information we provide physicians may help prevent an error and avoid the consequences for physician as well as patient.

—Jim Henderson, Director
Medical Library Service
College of Physicians & Surgeons of BC

References

1. Hébert PC, Levin AV, Robertson G. Bioethics for clinicians: 23. Disclosure of medical error. CMAJ. 2001;164:509-513.  http://www.ecmaj.ca/cgi/content/full/164/4/509 (February 2001; retrieved 4 June 2002). PubMed Abstract
2. Moorhouse J. Counting medical mistakes in Canada’s hospitals. Can Healthcare Manager 24 May 2002.  http://www.chmonline.ca/chmonline/story2.asp?ArticleID=485 (24 May 2002; retrieved 4 June 2002).
3. Shoesmith J. No room for error. Can Healthcare Manager 1 Feb 2002.  http://www.chmonline.ca/chmonline/story.asp?ArticleID=386 (1 February 2002; retrieved 4 June 2002).
4. Crocco AG, Villasis-Keever M, Jadad AR. Two wrongs don’t make a right: Harm aggravated by inaccurate information on the Internet. Pediatrics 2002;109:522-523. PubMed Abstract
5. Layde PM, Cortes LM, Teret SP, et al. Patient safety efforts should focus on medical injuries. JAMA 2002;287:1993-1997. PubMed Citation