Medical Errors in Healthcare

In the June, issue Fierce Healthcare had an article that talked about the rise of hospital medical errors in state was Massachusetts. The Boston Globe reported that errors were on the rise however, the Department of Public Health states, that is good. The report showed that 821 Serious Reportable Events (SRE) in 2014, an increase of 9 from 2013. Massachusetts officials cautioned that the increase does not indicates that hospital are less safe but say that it is an indication of more accurate data. Error reporting increase when a new error reporting data system was implemented in 2013. When the National Quality Forum standards was updated in 2012 errors jumped 70 percent between 2012 to 2013.  These new standards reported 290 serious injuries or deaths from a fall in 2014, a slight increase from 2012. The number of wrong site surgeries decreased, from 36 to 24, wrong sight surgeries and foreign objects left behind remained relatively the same.

Mayo Clinic researchers identified Major surgical errors used human factors analysis to identify  69 never events, including surgery on the wrong person, the wrong site or wrong side of the body, among the 1.5 million invasive procedures performed over 5 years, they found 628 human factors contributed to the errors overall, roughly four to nine per event. Nearly two-thirds of the mayo never events occurred during relatively minor procedures such as anesthetic blocks, line placements, interventional radiology procedures, endoscopy and other skin and soft tissue procedures. Even though there were multiple missteps that occurred there were four major identifiers  for the potential causes, such as stress, mental fatigue, miscommunications, unsafe actions this is where clinicians convince themselves they are seeing what they want to see, inadequate supervision and organizational influences.

Steps to prevent never event errors Mayo clinic follows Joint Commission’s protocol such as briefings and huddles before surgery, surgeons pausing before making the first incision. Surgical teams at Mayo have also implemented World Health Organization’s recommended safety checklist.

This problem is existing all throughout healthcare this is just information on one hospital study. The opportunities for error reporting software is limited and the ability to measure different parameters of hospital medical errors is at best difficult.