Talking with Patients and Families about Medical Error: A Guide for Education and Practice

2. What Is a Medical Error?

10 This book is about difficult conversations that occur in the aftermath of adverse events and medical error. In order to properly frame the principles and guidance that we recommend, however, some background discussion of definitions, historical considerations, and conceptual distinctions is necessary. Although the patient safety movement has matured considerably over the past several years, efforts to create a common set of definitions, categories , and concepts have not been uniformly successful. In fact, the image of the Tower of Babel has been invoked to illustrate that “a bewildering language of medical error and iatrogenic injury has evolved.”7 In one of the seminal works on the nature of human error (Human Error), James Reason offered the following working definition: “Error will be taken as a generic term to encompass all those occasions in which a planned sequence of mental or physical activities fails to achieve its intended outcome, and when these failures cannot be attributed to the intervention of some chance agency.”8 Reason goes on to describe ways of classifying errors, including the categories of “active” and “latent” errors. His work, particularly his understanding of the nature and complexity of latent (or systems) errors, has been very influential in health care. Against this backdrop, several definitions of medical error have appeared in connection with patient safety. The Agency for Healthcare Research and Quality (AHRQ) considers medical error to include “an action taken” or “an action that is not taken” that results in or has the potential to result in harm to patients. The AHRQ further refers to common categories of errors such as “active failures” versus “latent conditions,” and T WO What Is a Medical Error? WHAT IS A MEDICAL ERROR? 11 “slips” versus “mistakes.” The federal Quality Interagency Coordination (QuIC) Task Force focuses on whether the event is preventable, treating medical errors as “adverse events that are preventable with our current state of medical knowledge.” This idea is reflected in one of the most concise definitions of medical error, used by a number of leaders in the patient safety movement, as “a preventable adverse medical event.”9 Other definitions focus on how to determine whether an error has occurred. For example, Smith and Forster propose that an action (or inaction) is a medical error if so characterized by “skilled and knowledgeable peers.”10 They further divide medical errors into one of three categories : errors of skill, rule, or knowledge. While they use the term to include only unintentional acts, they include in their definition mistakes that are “caught” before the patient is harmed. In an article in Nursing Ethics, Nancy Crigger discusses a number of the more common definitions of medical error and then proposes four characteristics of medical error from an ethical point of view: (1) there is lack of intentionality (malevolent acts/omissions are not “mistakes”); (2) harm is not required (though such harm may be required to show legal negligence); (3) there is an element of “choice” (predetermined acts cannot involve “mistake”), and (4) there is responsibility (culpability), based on the element of choice.11 In addition to being aware of the different ways in which medical error is defined by scholars in the field, health-related government, and private organizations, it is important to note that individual clinicians and patients may have their own views on what constitutes an error. For example, in a study of operating room team members (nurses, anesthesiologists , surgeons) and patients, all respondents talked about error as a “deviation from standards of practice.”12 In this study, when the standard of care seemed ambiguous, participants were more apt to talk about an accident, “act of God,” or “honest mistake.” In these circumstances, they were also more apt to consider the seriousness of an adverse outcome in deciding whether an error had occurred. Some studies have shown that patients may differ from clinicians in their views of what constitutes an error. For example, patients appear to have a broader concept of error, which includes breakdowns in the patient-provider relationship and difficulty in accessing care,13 poor 12 TALKING WITH PATIENTS AND FAMILIES ABOUT MEDICAL ERROR communication and interpersonal skills, and poor service generally. 14,15 In another study of patients’ responses to self-identified “mistakes,” patients interpreted a variety of actions as errors—including failure to pass on telephone messages, inability to get timely appointments, rudeness, and lack of time and attention.16 In contrast to “error...