Medical Errors

Types of Medical Errors

Wrong Side Surgery	Wrong Procedure	Medication Errors	ABO Mismatch e.g. Jesica Santillan	Laboratory Errors
Other Errors
Not Following Guidelines:	Hypertension	Cholesterol	Diabetes	Heart Attack
Heart Failure	Asthma
Other Sources of errors	Reduced Staffing	Greed		J CAHO - Study of Sentinel Events

    Deaths due to Cutbacks in Staffing
Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction.
             JAMA 2002 Oct 23-30;288(16):1987-93
   Excess patient load for nurses associated with a 7% increase in the likelihood of death for each excess patient per nurse.

GREED
   OPERATING PROFIT - Mining Medicare:       How One Hospital Benefited on Questionable Operations
   New York Times August 12, 2003 A-1 Jonathan Kirshner for The New York Times
        Could it possibly be that doctors at his hospital in Redding, Calif., were cracking open the chests of perfectly healthy people?
      Tenet Healthcare agreed to pay $54 million to the government to resolve accusations that Redding Medical doctors conducted unnecessary heart procedures and operations on hundreds of healthy patients.
        Until federal agents raided Redding last fall, Tenet's business model was based on maximizing the dollars it could collect from Medicare, the nation's biggest buyer of health care. And Medicare's complex formulas
     - the template for private insurers, as well — reward some kinds of health care more richly than others, and few more richly than cardiac care.
         On multiple occasions, staff cardiologists raised concerns about the heart program and asked for an independent peer review. None was undertaken.

   JCAHO Sentinel Event Database (2005)

   The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) reviewed “Sentinel Events” to study the root causes of adverse patient outomes.
         See: The Joint Commission’s Sentinel Event Database. 2005.

Their 2966 sentinel events included:
415 inpatient suicides
370 events of surgery at the wrong site
365 operative/post op complications
326 events relating to medication errors
221 deaths related to delay in treatment
144 patient falls
124 deaths of patients in restraints
107 assault/rape/homicide
85 transfusion-related events
84 perinatal death/injury
57 infection-related events
57 deaths following elopement
51 fires
49 anesthesia-related events
511 “other”

    The following root causes were identified (in decreasing order of occurrence);
        Organization culture
        Care planning
        Continuum of care
        Leadership
        Environmental safety / security
        Procedural compliance
        Competency/credentialing
        Availability of information
        Staffing
        Patient assessment
        Orientation/training
        Communication

For more information, Visit the Joint Commission Web Site

How Many Medical errors? .
What kind of errors?, Wrong Side Surgery, Not Following Guidelines, Reducing Errors,
Doctor Discipline