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Vol. 66, No. 1 2015
Northeast Florida Medicine
CME
Prevention of Medical Errors:
Root Causes and Strategies to Avoid Errors
According to the Florida Board of Osteopathic Medicine,
the most common medical errors as of 2014 involved inap-
propriate prescribing of opioids in patients where there may
have been a diagnostic omission or commission related to
addiction, psychiatric conditions or diversion, delay or failures
in diagnosing cancer, retained foreign objects in surgery and
wrong site/wrong patient surgery, surgical and pre-operative
evaluation complications/errors and prescribing, dispensing,
administering or using non-FDA approved medications
and devices. The Florida Board of Medicine has identified
the following as the top five most misdiagnosed conditions
currently as being cancer related conditions, neurological
related conditions, cardiac related conditions, timely response
to surgical and post-operative complications and urological
related conditions. This article focuses on several medical
errors, the root causes and prevention techniques.
Wrong Site/Procedure/Patient Surgery
Few medical errors are as vivid as those that involve patients
whohaveundergonesurgeryonthewrongbodypart,undergone
the incorrect procedureorhadaprocedure intended for another
patient. These “wrong-site, wrong-procedure, wrong-patient
errors” (WSPEs) have been termed “Never Events” as they are
errors that shouldnever occur and that demonstrate underlying
safety problems. In February 2009, the Centers for Medicare
and Medicaid Services (CMS) announced that hospitals will
not be reimbursed for any costs associated withWSPEs. (CMS
hasnot reimbursedhospitals for
additional
costs associatedwith
many preventable errors since 2007.)
When the then-president of the Joint Commission,
surgeon Dennis O’Leary, MD, unveiled mandatory rules
to prevent operations on the wrong patient or body part,
he did not mince words. “This is not quite ‘Dick and Jane,’
but it’s pretty close,” he declared in an interview with the
Washington Post
on January 21, 2011, about the “universal
protocol” to prevent wrong-site surgery.
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These rules require
preoperative verification of important details, marking of
the surgical site and a timeout to confirm everything just
before the procedure starts.
Effective errors prevention activity that O’Leary cited in-
cludes ensuring that x-rays are carefully reviewed, accurately
documented and, if hung, hung correctly, checking arm
bands and having all teammembers reaffirmpatient identity
and planned procedure. However, in 2012, researchers and
patient safety experts said that the rate of WSPEs in the
United States had not improved, but may actually be getting
worse. Forty-eight cases were reported inMinnesota in 2010,
up from 44 in 2009 and Pennsylvania has averaged about
64 cases for the past few years. Based on data provided by
individual states, Joint Commission officials estimate that
wrong-site surgery occurs 40 times a week.
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Mark Chassin, MD, current TJC president, speaking at the
Joint Commission Center for Transforming Healthcare Con-
ference on June 29, 2011 said he thinks errors are increasing,
in part, because of escalating time pressures and throughput
demands on surgical teams. Preventing wrong-site surgery also
“turns out to be more complicated to eradicate than anybody
thought,” he said, because it involves changing the culture of
hospitals and getting doctors who typically prize their autonomy,
resist checklists and underestimate their propensity for error, to
follow standardized procedures and work in teams. Studies of
wrong-site errors have consistently revealed a failure by physi-
cians to participate in a timeout. Timeout is the minimal delay
just before incision to ensure correct patient, procedure and
site according to Dr. Chassin and co-presenters: Mary Cooper
MD, Lisa Lewis, RN, and Rudy Manthei, MD.
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Philip F. Stahel, MD, director of orthopedic surgery at
Denver Health Medical Center was lead author of a 2010
study evaluating 132 WSPE cases reported to a Colorado
malpractice carrier. The cases were reported between 2002
and 2008, and one-third resulted in death or serious injury.
Among themwere three men who underwent prostate cancer
surgery although they were cancer-free. In 72 percent of cases
there was no timeout.
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By Vicki-lynne Gloger, MSSM, SFHM
Address Correspondence:
Vicki-lynne Gloger,
Administrator Baptist Health System Hospitalist Programs
Jacksonville, FL
Abstract:
This article focuses on medical errors and the root
causes for why they occur, case reviews of some types of errors and
strategies to avoid them. After reading this article, the physician
should be able to identify common medical errors according to the
Board of Osteopathic Medicine and the Board of Medicine, at
least two root causes for each and at a minimum of two strategies
to effectively avoid these medical errors.
