Dat Vuong & Sean Bringhurst

HMGT 6320
December 12, 2014
Is it Human to Error?
The healthcare system with the motto of first, do no harm, is supposed to
provide relief and comfort to patients rather than doing harm. Medical errors threaten
patient safety and represent a serious public health problem, being the third leading cause
of death in North America9. It is estimated to cost between $17-29 billion per year in lost
income, disability, household production, and additional health-care costs2. What is
considered a medical error has different meaning amongst organizations due to a lack of
standardized nomenclature and the use of overlapping definitions. For a clear and
universal definition throughout this paper, a medical error is the failure of a planned
action to be completed as intended or the use of a wrong plan to achieve an aim 2. The
main focuses of this paper are medical errors inside of hospital settings. Not only do
medical errors produce physical repercussions but also psychological repercussions to
both the patients and health professions such as the loss of morale in the latter.
There are instances where there is not any evidence of harm to the patient, making it
difficult to estimate the number of medical errors that occur each year in the U.S. The
highest error rates that produce the most detrimental effects take place in the intensive
care units, operating rooms, as well as emergency departments9. A phenomenon known,
as the July effect is something that occurs whenever the new residents arrive in teaching
hospitals, provoking an increase in medical errors. Interns have admitted to falling asleep
even during surgeries. In a journal published on the National Center for Biotechnology

Information (NCBI) a web based survey across the U.S. was conducted in which 2737
residents in their first postgraduate year completed 17,003 monthly reports. Interns that
worked five or more extended duration shifts per month reported more attention failures
during lectures, rounds, and clinical activities, including surgery and reported 300% more
fatigue related preventable adverse events resulting in a fatality11. It was concluded that
sleep deprivation is a major contributing factor to human errors; in the event of being
awake or more than 24 hours, medical interns double or triple the number of preventable
medical errors11. The increased risk factors are associated with fatigue, depression,
burnout, unfamiliar settings, and time pressures.
Dr. John T. James, a toxicologist at NASAs space center in Houston who runs an
advocacy organization called Patient Safety America outlines the types of preventable
adverse events (PAE) that are important. These events are a spectrum of errors that can
happen in a hospital setting. The four categories of preventable adverse events are errors
of commission, omission, communication, and context. Errors of commission happen
when a poor decision harms a patient either because it was the wrong action or that it was
the right action performed improperly. Errors of omission occur whenever there is
evidence of the failure to follow evidence based guidelines and are much more difficult
to detect. Errors of communication can happen between 2 or more providers and
also between providers and patients. Such as was the recent case at THR with the
first U.S. incidence of Ebola earlier this fall with the nurse failing to mention to the
physician that the patient had mentioned to the nurse that he had visited West
Aftrica. Errors of context occur whenever a physician fails to take into account unique
constraints in a patients life that could have a negative impact on recovery. Diagnostic

errors resulting in delayed treatment, the wrong treatment, or no effective treatment may
also be considered separately, although a small subset of these might be included in
errors of commission or omission2.
In September of 1999, the Quality of Health Care in America Committee of the
Institute of Medicine (IOM) published a hallmark report on medical errors: To Err is
Human: Building a Safer Health System. It was a compilation of studies that focused on
Colorado, New York, and Utah estimating that 44,000 to 98,000 Americans died in U.S.
hospitals in the year of 1997 due to preventable medical errors. These were errors in
preventative care, treatment, diagnosis, and follow-up. These estimates include alarming
occurrences such as, transfusion of incompatible blood produces, foreign objects left in
bodies, medication errors, equipment failures, and mistaken identities of patients or body
parts. In addition, the Centers for Disease Control and Prevention (CDC) have estimated
that there are 1.7 million occurences10 of nosocomial infections or hospital associated
infections each year. Nosocomial infections are one of the most common complications
and may be accountable for 90,000 to 100,000 deaths per year in the U.S. (John P. Burke,
Infection Control) 5,6.
In 1999 only one-third of the states had mandatory reporting laws. The IOM
recommended a dual reporting system which comprised of mandatory reporting laws
that should be established by Congress to create a national system that is operated by the
National Forum for Health Care Quality Measurement and Reporting in order to collect
reports of serious errors that take place in hospitals and health care settings. These serious
adverse events are easy to identity and hold the facilities accountable as well as helping
them to develop a voluntary reporting system that will complement the mandatory

system. This voluntary system focuses more on a broader set of errors that are less
serious and have had minimal harm. This way the delivery systems weaknesses could be
identified and improved before these occurrences manifest into a more detrimental end
result2. The information collected will help healthcare organizations in improving the
safety and quality of care. These voluntary efforts will prove to be difficult to encourage
unless Congress is able to enact laws protecting the confidentiality of the information that
is collected preventing the chances of the disclosed information being subpoenaed and
used against the informants firm in a lawsuit. By 2008 twenty-seven states had
operational data collection systems. From the Institute for Healthcare Improvement
website they outline the difficulty that arises in reporting medical errors, Traditional
efforts to detect medical errors have focused on voluntary reporting and tracking of
errors. However, public health researchers have established that only 10 to 20 percent of
errors are ever reported and, of those, 90 to 95 percent cause no harm to patients.
Hospitals need a more effective way to identify events that do cause harm to patients, in
order to select and test changes to reduce harm.4. Some medical errors may arise due to
inexperienced physicians and nurses as well as new procedures, and complex or urgent
care. The majority of these errors are a result of poor communication, faulty systems, and
processes that arent well adept in providing complex care. In the Joint Commissions
Annual Report on Quality and Safety in 2007, it was discovered that the lack of
communication between healthcare providers caused over half of the critical adverse
events in the accredited hospitals3. A common saying is that good people are working in
bad systems2.

After the IOM report was passed, there was an immediate response from the
Congress that launched hearings on patient safety in December 2000 that ultimately
allocated $50 million5 to the Agency for Healthcare Research and Quality to encourage
efforts that are targeted at reducing medical errors. Most of it has been funding
information technology development instead of error prevention research, the first three
years of funding established medical error research as a legitimate, critical, and
underdeveloped academic field. Their progress also included: developing and
testing new technologies to reduce medical errors as well conducting large scale
demonstration projects5 to test the effectiveness of safety interventions and error
reporting strategies. The Agency for Healthcare Research and Quality (AHRQ), a
segment of the Department of Health and Human Services, is the focal point for
patient safety at the federal level5. They created the Center for Quality
Improvement and Patient Safety to gather and disseminate information on
healthcare quality measurement and to implement evidence based preventive
practices5. Their booklet on www.ahrq.gov is a book on tips that promotes individual
consumers to take an active role in selecting and evaluating their care such as selecting
doctors, hospitals, and treatments to improve the quality of health care services received.2
In July 2005, Congress furthered their efforts of supporting error monitoring with The
Patient Safety and Quality Improvement Act, which encourages voluntary and
confidential reporting of adverse events5 and helped to create a certification process for
patient safety organizations to collect and analyze patient safety information5. The
Patient Safety and Quality Improvement Act, also makes non-governmental organizations
eligible to collect medical error reports that are protected from legal disclosure5. Three

states: Florida, Nebraska, and Pennsylvania rely on these organizations to analyze reports
of medical errors from facilities throughout the state.
State health departments began to work among hospitals to carry out root-cause
investigations, create protocols to address known errors, as well as implement best
practices to prevent future errors. The state departments efforts have helped The
National Quality Forum, a non-profit organization to produce a list of 28 serious
reportable never events that are used to increase system-wide quality improvement in
health care.5 Some state Medicaid programs have also refused to reimburse providers for
some or all of the events on the NQF list5. As of October 2008, the federal government
no longer reimbursed care for ten reasonably preventable conditions caused by medical
errors these include: bed sores, fall injuries, and a few hospital-associated infections in
order to promote patient safety. More strict federal regulations have been established
such as The Centers for Medicare and Medicaid Services requiring hospitals to report
forty-two measures of quality, including some measures of medical errors, in order to
receive a full payment update to rates in the following fiscal years5.
Many state hospitals have also entered voluntary agreements to refrain from
billing for medical errors as well as insurers in seven states such as Cigna, Blue Cross
Blue Shield, Aetna, and WellPoint ceasing coverage for procedures to correct medical
errors5.The Centers for Disease Control and Prevention (CDC) have been monitoring the
incidence of health care associated infections and have operated a National Nosocomial
Infections Surveillance since the early 1970s, which as of 2005 included at least 300
hospitals 5. In 2005 the National Nosocomial Infections Surveillance System was
replaced by the National Healthcare Safety Network (NHSN) which also incorporates

surveillance data from the Dialysis Surveillance Network and the National Surveillance
of Healthcare Workers5.
There are also non-governmental contributors in efforts of documenting and
preventing medical errors. The Joint Commission on Accreditation of Healthcare
Organizations, the American Hospital Association, and the American College of
Physicians are some examples of professional associations that are reinforcing state and
federal efforts to improve patient safety standards5. Medicare and Medicaid have
followed in the footsteps of these private arrangements and are aiming to provide
financial incentives for safeguards on patient safety5. It is apparent that the healthcare
delivery system is where the work needs to be done in order to improve the patients in a
hospital. A patients traditional healthcare delivery requires a variety of complex
interlinked systems5 where different providers are often involved in caring for a single
patient but factors at every level of these systems affect the rate of medical errors and the
repercussions that may arise. The airline industry has been constantly compared with the
medical industry and it could be noted that accidents can potentially be reduced with
proper organizational design and management. The airline industry set legal liabilities for
failing to report an error. A patient whom experiences an unreported medical error also
is an abused victim, failure to report an incident allows other errors to propogate.2 It is
thought that the unreported errors will and can continue to grow because they are sliding
under the rug. Airlines complaints are reported as a matter of public record and similar
gripes of healthcare delivery to improve culture and performance to help bring to light
errors that might have been unreported.

Dr. John T. James compiled a study in which he identified 4 steps to getting solid
data on what leads to medical errors in the hospital setting and what may results of these
errors. His method included: (1) Distinguishing different types of preventable adverse
events (PAE) that may occur in hospitals, (2) characterize preventability in the context of
the Global Trigger Tool (GTT), (3) search contemporary medical literature for the
prevalence and severity of PAEs that have been enumerated by credible investigators
based on medical records assessed by the GTT, and (4) compare the studies found by the
literature search.3 From Dr. James in depth study he was able to update the estimated
44,000 to 98,000 from to Err is Human to 210,000 to 440,000 deaths per year in the
United States using his tactics to gather information. To put this estimation into
perspective it is outlined below in Table 1.
Table 1.
The Global Trigger Tool
(GTT) is the primary tool
that Dr. James used to
find, compile, and
evaluate the information
on different PAEs from 4
different limited studies. GTT works by depending on a systematic review of medical
records by trained professionals to find specific clues or triggers (i.e. medication stop
orders, abnormal laboratory results, complication of procedure, transfer to higher level of
care) suggesting that an adverse event has taken place. Shortly after, the trained
professional identifies the situation one or more physicians must review and validate the

case. Since its debut in late 2003 the GTT has spread around the world. It is now being
incorporated in hundreds of hospital settings in multiple countries to help improve patient
care by monitoring adverse events. The widespread use of the GTT has provided new
opportunities to track adverse events, trends, common happenings in different
geographical locations, clarify definitions, and update materials and common practices4.
Evidence of the effectiveness of the GTT in helping identify medical errors or adverse
events can be seen in the following example from Dr. James study. Investigators looked
at the medical records of 780 randomly selected patients chosen to represent the 1 million
Medicare patients discharged from hospitals in the month of October 2008. The total
number of hospital stays for the 780 patients during this period was 838 due to a small
number of the beneficiaries being hospitalized and discharged more than once during the
one-month index period. Using primarily the GTT developed by the Institute for
Healthcare Improvement to find adverse events, investigators found 128 serious adverse
events (level of harm ranging from required prolonged hospital stay, permanent harm, life
sustaining intervention required, or contribution to death of patient) that caused harm to
patients, and in the cases of 12 patients, an adverse event contributed to their death.
Seven of these deaths were medication related, two were from blood stream infections,
two were due to a procedure where something was removed from the body (air, bodily
fluids, or bone fragments) and the 12th one was linked to ventilator-associated
pneumonia. Only two of these events were on the National Quality Forum list, and none
were on the Medicare Hospital-Acquired Conditions list. The authors of this report
estimated that events contributed to the deaths of 1.5% (12/780) of the 1 million
Medicare patients hospitalized in October 2008. That amounts to 15,000 per month or

180,000 per year. Note the percentage of deaths per hospitalization was slightly lower at
1.4% (12/838). The authors did not explicitly state the percentage of the lethal adverse
events that were preventable, but given their description of the events it seems that most
were preventable. Overall, physician reviewers estimated that 44% of the serious medical
events were preventable.3
The Minnesota Department of Health published a case study in which a little
nurse miscommunication led to a patient death. The case study speaks of an 85-year-old
patient that had an open reduction internal fixation (ORIF) procedure done after
fracturing her hip. The procedure is an intensive, emergency type procedure that leaves a
patient with plates, screws, rods, and/or pins. She was considered a medically
compromised patient having other health issues that would require certain medications to
be taken and certain medications to stay away from. When the health care professionals
were reviewing and rewriting the patients Medication Administration Record (MAR) the
nurse in charge of doing so marked a medication that she thought had been duplicated
between the patients old record and new record upon doing so the nurse had to take a
phone call, not completing the process of transferring the records. A second nurse entered
and finished the task for the first nurse by double-checking the orders and removing the
old MAR. A third nurse, administering medications, misinterpreted the mark the first
nurse made by one of the medications and did not administer the medication to the
patient. 4 days after the ORIF procedure the patient passed away from cardiac arrest due
to a lack of medication to treat congestive heart failure.6
In an additional case study where a 67-year-old gentleman had a total knee
replacement and failed to receive proper care from a nurse in post operation leading to

the patient passing away. Immediately following the procedure in the recovery area the
patient exhibited signs of difficulty that were not attended to in a timely manner, leading
to further complications with the patient and a subsequent fatality. Upon investigating
this patients tragic death the nurses mistakes were identified. Experts determined that
the nurse breached the standard of care in the following areas, including: failure to
formally clarify her work assignment, failure to properly asses the patient upon his
admission to the medical-surgical care nursing unit, failure to follow physician
postoperative care orders, failure to notify the physician of changes in the patients
condition, and failure to initiate CPR immediately upon finding the patient to be
unresponsive.7 Hindsight it is easy to identify where the nurse went wrong and what
medical errors occurred which gives more reason for such occurrences to be published.
The two previous cases could have been prevented if there was a protocol in place,
consisting of a second person on staff double checking what the nurse was writing or
doing. Identifying such cases and publishing them to the healthcare community is a great
place to start. Recognizing similar situations as they arise and what needs to take place in
order to save a person will come more naturally as data is made available for healthcare
professionals to review and implement.
There may not be a single root cause but rather, a framework in which the factors
could be analyzed to come up with a proposed solution. The de-fragmented American
healthcare delivery system makes it easier for things to go awry in scenarios where
multiple providers in different settings have numerous handoff of patients2 resulting in
lack of coordination. The patient is left to plan out their care leaving the risk of patient
information to be overlooked due to one provider lacking the proper tools to do so.

Mistakes can be overlooked such as the simple dilution of full strength drugs before
being administered to patients could prove to be deadly.
With the cases and data presented it could be concluded that patient safety for
patients could be improved by using a systems approach. This entails looking at the
hospitals organizational culture, design, and management in order to find the root causes
of the medical errors based on the data that is collected from the mandatory reporting
laws as well as mandatory reporting systems that will be encouraged. The
implementation of improvements will need support from a culture of safety that must first
be developed then followed by the hospitals strong leaders such as clinicians, executives,
and governing bodies. So the jobs and workforce must be introduced to processes that
revolve around safety principles that are ingrained into their everyday tasks. This could
be done with the simplification of equipment, supplies, and processes that are less reliant
on the care providers memory. Implementations of systems that continuously monitor of
patient safety could prove to help improve the reliability and safety of care for patients.
An example is the creation of an automated medication order entry system to reduce the
medication errors that are occurring frequently in hospitals.
To date, there is not a comprehensive nationwide monitoring system that exists
for error reporting and the recent attempts to estimate error rates show little movement
in actual error incidence nationwide5. Progress into the frontier of medical errors and
understanding their importance is becoming realized and carried out. Medical errors
cannot be solved with a single solution but rather a framework that combines the
concerns that have been addressed in this paper starting with a more integrated healthcare
delivery system while simultaneously creating an organizational culture that has a

centralized theme of patient safety. While the medical industry has become more focused
and aware of medical errors, it should also be brought to the publics attention. That way
the general public may take a proactive approach after becoming equipped with the
knowledge and resources pertaining to medical errors. It is human nature to make errors
but it is also human nature to look after one another as generations age and others
emerge. It is a pandemic in which the severity could be resolved as a result of the
simultaneous efforts from both the general public and healthcare professionals alike.

Sources
1.http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3211566/
2.To Err is Human
https://www.iom.edu/~/media/Files/Report%20Files/1999/To-Err-isHuman/To%20Err%20is%20Human%201999%20%20report%20brief.pdf
3. A New, Evidence-based Estimate of Patient Harms Associated with Hospital Care
http://journals.lww.com/journalpatientsafety/Fulltext/2013/09000/A_New,_Evidence_bas
ed_Estimate_of_Patient_Harms.2.asp
4.Global Trigger Tool
http://www.ihi.org/resources/Pages/Tools/IHIGlobalTriggerToolforMeasuringAEs.aspx
5. Study of to Err is Human and its progress
http://www.yale.edu/yjhple/issues/vix-i1-win09/docs/feature.pdf
6. Nurse miscommunication and inconsistent chart modification leads to elderly patient
passing.
http://www.health.state.mn.us/patientsafety/toolkit/scenario_nhmederror..pdf
7. Nursing Cases with good figures and suggestions on how to approve
http://www.nso.com/case-studies/casestudy-article/346.jsp
8. Table 1.
http://www.readinessrounds.com/blog/2013/10/07/preventable-medical-errors-a-leadingkiller-in-the-u-s/
9. Updated Statistics

http://www.npr.org/blogs/health/2013/09/20/224507654/how-many-die-from-medicalmistakes-in-u-s-hospitals
10. CDC Estimate
http://www.nytimes.com/2010/02/27/business/27germ.html?em=&adxnnl=1&adxnnlx=1
267412412-yP2bfl/3pu4+g34XVmluJA&_r=0
11.Case study of prolonged work hours
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1705824/