WHAT TO DO WHEN A MEDICAL ERROR HAS OCCURRED

At some point in a physician’s career, he will be involved in a situation in which a medical error has been made. It might be the physician’s error, it might be someone else’s error, but sooner or later it will happen. Even if it is a major error that has resulted in permanent disability or death, it should not be “covered up.”

On August 29. 2005 the Patient Safety and Quality Improvement Act of 2005 was signed into law. Basically this law creates legal protection for reporting medical errors—and data regarding medical errors—in order to encourage voluntary reporting. This safeguard was created to protect providers and public and private organizations that collect and analyze patient safety data in order to improve patient safety. A complete copy of the law is available from the U. S. Government Printing Office. The web address is http://www.gpoaccess.gov; the mailing address is 732 N. Capitol Street, NW, Washington, DC 20401

Reporting Medical Errors Internally
Health care personnel need to make sure they are aware of all systems in place in a facility or private practice in which they are working, and work within those systems. When an error-or a “near miss”-occurs it should be reported to the person in charge immediately.

Reporting of the “near-miss” is important because it can help flag a possible flaw in the system that can be addressed before a tragic error occurs.

The health care climate needs to be one in which reporting an error is as non-threatening as possible. People are going to make mistakes, even the most careful, thoughtful, thorough people. Reporting an error must be part of the ordinary routine, and simple to do. It must also be non-punitive so that staff does not have to be afraid of repercussions.

Reporting Medical Errors to the Patient or Patient Family
The following steps should be followed:

• Inform the patient in a simple, direct manner
  
• Avoid placing blame or directing it toward others
  
• Explain any and all possible ways to correct the error.
  

If the error has resulted in permanent damage or death, the physician should be prepared to deal with the patient’s and/or the family’s anger. The physician must avoid becoming defensive. The physician must avoid naming colleagues who may have been involved in the incident, or who may have committed the same error. The physician must retain his/her composure and initiate whatever action is necessary to reach the best possible result.

Ethical Questions in Reporting Medical Errors
Fortunately, most medical errors are not going to have devastating affects. And that is when physicians might face a personal dilemma about reporting a medical error. Perhaps, although the physician is either legally or contractually obligated to report all medical errors that she commits, or that she knows others have committed, the physician knows that if nothing is said, no one else will ever know. Maybe it is a very minor error. Or maybe a colleague made an initial error but was able to correct it without any harm to the patient, and again, no one but them will ever know. Should the physician report that error?

In order to decide, the physician must ask herself one very important
question: “If I don’t report it, how will it make me feel about myself?”

The physician must then move forward based on the answer. However, one important fact should be kept in mind-we often learn from our mistakes, and sometimes the best possible consequence of a medical error is that systems are put in place to make sure it never happens again.

An outstanding example is the case of Ben Kolb, the 7-year old discussed earlier. The reason Ben was given such a huge overdose of epinephrine is that it had been poured into a sterile container in the operating room that looked exactly like the container storing the dose he should have received. Because of that, the staff at the hospital made two important changes:

1. They initiated a better labeling procedure in the operating room,
   
2. Two staff members must be present when medicines are transferred from labeled bottles to the syringe or container used in the operating room.
   

But the hospitals’ staff went even further. The anesthesiologist appeared in a video in which he spoke frankly about the mistake he made, and how the hospital responded. That information can help other facilities avoid the same tragic mistake.

LEARNING FROM OUR MISTAKES
The one silver lining in the cloud of medical errors that currently hangs over the entire practice of medicine is that just as human beings are going to make mistakes, we are going to learn from them. And we are going to learn how not to make the same mistake twice.

One shining example is the VA healthcare system, the largest health care system in the country. They put a bar-coding system in two of their hospitals in Kansas that works as follows:

1. Each patient and nurse wears a barcode strip, and an identical strip is
   also attached to medications.
   
2. Before giving a patient a medication, the nurse scans all three strips into
   a computer that verifies that the medication is correct, is being given
   correctly, and will not cause drug interactions.
   
3. If the computer identifies a problem, it flashes a warning. If everything
   is okay, it records the activity and maintains a permanent record.
   

Over the 5-year period in which the bar codes were tested, the medication error rate dropped by 70%.

The VA also made other important changes, including:

• Storing hazardous medications away from patient care areas
  
• Creating a culture of cooperation in which the focus is correcting the system, not placing blame
  

The highly respected Dana Farber Cancer Institute is another example
of an institution that took immediate steps to prevent a tragic error
from ever recurring.

After two women died as the result of errors in chemotherapy dosage, a computer system was installed that took over many functions in writing and filling prescriptions. The steps included in the system are:

1. Physicians no longer write prescriptions by hand. Instead, they fill them out electronically and include pertinent information:

• The patient’s personal information
  
• The name of the drug
  
• The dosage
  
• The number of days for which the drug should be given
  

The form is put into the computer system that has been programmed with vital information about the drug. If the doctor seems to have made an error, the computer signals the error.

2. A nurse double-checks the drug’s information in the computer before ordering the drug from the pharmacy.

3. The pharmacist then checks for patient allergies, and potential drug interactions with other drugs or foods.

4. The drug goes directly from the pharmacy to the nurses’ station and 2 nurses must check the label against the patient’s wristband to make certain the right patient gets the right drug.

Even more impressive, Dana Farber created a non-punitive system for reporting medical errors so staff would feel they were being supportive of the system. This policy brought about a significant increase in error reporting, and therefore creates a much better climate in which safer systems can be implemented.

Health care professionals cannot eliminate medical errors, but they can work harder to prevent them. They can create safer systems. They can increase the chances of reducing the devastating effects of medical errors. They can do a better job of protecting their patients.