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C H A P T E R 4 MEDICAL ERRORS DAVE NEILIPOVITZ The case of Jesica Santillan attracted worldwide attention in 2003, This 17-year-old woman suffered from congenital heart disease. Her family moved to the United States because a heart transplant would eventually be required. She underwent a heart-lung transplant at a leading centre. During the procedure, a horrible mistake became evident: the organs were from a person with an incompatible blood type. Despite heroic efforts including a second transplant, she died 15 days later. Although the leading surgeon accepted full responsibility, many questions were asked. The most haunting question was how could such afundamental errorfor such asimple yet critical issue occur? Headlines were made around the world when the Institute of Medicine estimated that up to 98000 people die each year in the United States as direct result of medical errors.1 Dramaticanalogies to a747 jetliner full of patients dying daily2 or a major motor company losing an employee every day3 were used to describe a problem of astonishing proportions. Not surprisingly, the topic ofmedical errors has now become one of the leading public concerns. Although this issue is not a new one, it is clear that society is demanding dramatic changes and improvements in this area. The "head in the sand" attitude that has hitherto been taken to this taboo subject will no longer be tolerated.4 An exhaustive review on medicalerrors in this chapter is clearlynot feasible. Rather, the goal of this chapter is to introduce some of the important aspects of the problem and illustrate how some of the strategies advocated by the ACES Program may help reduce the impact of medical errors. • Definition ofMedical Errors Historically, the circumstances that have resulted in adverse events in patients have been called "medical errors." A leading researcher in this topic suggests 27 that the use of the term has been unfortunate.Dr. Troyen Brennan suggests that this term has negative connotations: some synonyms would include blooper, blunder, goof—and numerous other derogatory names.5 Although few would question calling horrific mistakes such as amputating the wrong limb or transplanting an incompatible organ as nefarious errors, these are not representative of the vast majority of circumstancesthat result in adverse events.6 '7 Regardless of the appropriateness of the term, medical error will be used in this review. Thus, it becomes crucialto understand what constitutes an actualmedical error before embarkingon a discussion of the topic. The definition ofwhat constitutes a medicalerror unfortunately differs substantially depending upon who is defining it. The Institute of Medicine defines medical error both as the failure of a planned action to be completed as intended or as the use of a wrong plan to achieve an aim, whether or not the error results in harm.1 Wu et al.8 modified this definition by describinga medicalmistakeas a "commissionor an omission with potentially negative consequences for the patient that would have been judged wrong by skilled and knowledgeable peers at the time it occurred, independent of whether there were any negative consequences." They thus included inaction as an important source of error and, most importantly, suggested that actions must be judged in the context of when they were made rather than through retrospection. Thus, medical errors are the result of an action or an inaction and their being judged to be errors should not be dependent on whether a patient is harmed— in spite of the fact that it is often the severity of the injury that will bias individuals in determining whether or not an error has occurred.9 Someauthors argue that only mistakes that have adverse consequences should be the focus of error reduction programs. On the contrary, we will argue that although an error that has no adverse consequences is certainly not as devastating as one that results in someone dying, the end result should not diminish the fact that an erroroccurred.Smalland seemingly unimportant mistakes left unaddressed could potentially proceed towhat ultimatelybecomes a catastrophe. As discussed below, solving the cause of the problem often involves changing the environment in which it occurred. Thus, all errors should be addressed in some manner. One lastissue in the discussion ofmedicalerrorsis the subjectofnegligence. Negligence is often defined as the failure ofahealth careprofessional to meet the standard of care that would be expected within their community resulting in injury or harm.10 Negligence is certainly related to the topic of medical errors but the two should not be regarded as synonymous. Although negligence will...

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