Emily Jerry was two … Competing interests: The authors have declared that no competing interests exist. Moreover, this frequency seems higher than the global average of 33.5% [18] and as well as above the 18.0% frequency reported in the United States or the 27.0% reported in the European Union [19]. Participants were asked about their views on the potential role that health institutions have in the reduction of MEs. According to the participants, other MEs such as dispensing wrong medical results from lack of enough time to review orders for appropriateness which results in increased likelihood among care providers to make mistakes. The human factors include ignorance, lack of experience, training, carelessness, workload, and lack of attention. https://doi.org/10.1371/journal.pone.0217023.t002. First, the study was conducted in one hospital and pharmacists made up the majority of the sampled respondents therefore, the views expressed may not be generalisable. Burlington, MA: Massachusetts Coalition for the Prevention of Medical Errors, 2006. Paula Schulte couldn't survive a cascade of medical mistakes. Medication Errors - Around 1.5 million people are injured due to medication errors every year in the United States, according to the Institute of Medicine. For example, in the European Union, it was estimated that hospital readmissions and hospitalisations as a result of MEs account for between 8% and 12% of all reported cases [19]. “To Err Is Human” was an uneasy read; so is a September 2019 report on patient safety from the World Health Organization . Society and the media are generally intolerable of people making mistakes which may cause human suffering, and therefore cultivate a blame culture. The distribution of questionnaires was done online and in such a way that the researcher was not in a position to tell who completed the survey questionnaire. Advocates are fighting back, pushing for greater legislation for patient safety. "It's not just your physician or your surgeon who makes a difference in the quality of a patient's care—it's providers, staff and administrators working together at all levels of the health-care system who foster the right patient outcomes." A total of 44.7% of the participants express that the problem of MEs can be mitigated if health institutions created a better working environment for workers to reduce working hours and reconsider the system of shifts and considering to reduce the number of patients who admitted to the hospital. The pattern of behavior showed that 7.6% of physicians reported to have never been involved in medical errors, and among system failures, ‘overwork, stress or fatigue of health professionals’ was the most highly rated item. School of Pharmacy, University of Hertfordshire, Hatfield, United Kingdom, Affiliation: A total of 64.7% of the participants felt that health institutions should be more proactive in terms of performing regular analysis and evaluations. Yet, the fundamental mission of the health profession has been challenged with widespread and persistent medical errors. I have had time to heal. In Kuwait, there is a paucity literature detailing the causes, forms, and risks of medical errors in their state-funded healthcare facilities. Despite having fewer representation from nurses and physicians, a substantial input from a wide range of HCPs was obtained which gives more comprehensive insights and opinions on MEs in Kuwait tertiary hospitals. The participants were asked about relationship between colleagues as they may have a bearing in mitigating potential MEs. Fear of legal liability and prosecutions, staff are afraid of legal action, Fear of the consequence that may result from ME, Lack of seriousness in dealing with medical accidents, Some of the staff ignored MEs and indifference, Lack of feedback and fear of consequences. A range of different suggestions were provided including reporting through incident reports (68.7%), taking advice from colleagues that were more experienced (27.3%), and ignoring the incident (2.7%). It can be equated with learning new that is not easy to grasp. Methods . A medical error is a preventable adverse effect of care (" iatrogenesis "), whether or not it is evident or harmful to the patient. I ran a lot and made art. A comprehensive search was conducted in international databases (MEDLINE, Scopus and the Web of Science), national databases (SID, Magiran, and Barakat) and Google Scholar search engine. The respondents noted that fellow colleagues (49.7%) were to be held accountable for MEs, followed by the system used to run the hospital facility (40.3%), and the hospital administration (27.0%). Whether verbal or written, these issues can arise in a medical practice or a healthcare system and can occur between a physician, nurse, healthcare team member, or patient. PLOS ONE promises fair, rigorous peer review, “Top-ranked causes of death as reported by the CDC inform our country’s research funding and public health priorities,” says Makary. The literature findings are also in support of the present research results as a growing body of knowledge confirm the impact that lack of reporting on AEs, heavy workload, and miscommunication among care providers has on increasing the risk of MEs [12, 22]. http://www.euro.who.int/en/health-topics/Health-systems/patient-safety/data-and-statistics. David White, MD CCFP FCFP. Medical errors have become an important topic in current discussions of health care policy in the USA. The aim of this study was to explore undergraduate medical students’ attitudes towards patient safety in the low-income setting of the Gaza Strip. Storytelling shifts thinking from ‘rational and scientific’ patterns to reflective thought that calls forth a detailed context surrounding the experience. HCPs may be afraid for their reputation, career, future, and even their medical licenses if they admit to committing MEs [15]. 1.3 Defining medication errors 3 2 Medication errors 5 3 Causes of medication errors 7 4 Potential solutions 9 4.1 Reviews and reconciliation 9 4.2 Automated information systems 10 4.3 Education 10 4.4 Multicomponent interventions 10 5 Key issues 12 5.1 Injection use 12 5.2 Paediatrics 12 5.3 Care homes 13 6 Practical next steps 14 A ME is defined as a failure to achieve planned actions (errors of execution) or using wrong plans to attain an objective (errors that result due to planning) [1]. Medical terminology errors are a key instrumental tool to many hospital mistakes which affect the health of people and can even lead to loss of lives. Recent studies of medical errors have estimated errors may account for as many as 251,000 deaths annually in the United States (U.S)., making medical errors the third leading cause of death. Another study also reported that lack of in-depth experience and knowledge about pharmacological interventions among nurses and physicians can be a potential risk factor for MEs [11]. https://doi.org/10.1371/journal.pone.0217023.t004. identified the clinical consequences of severe MEs and noted challenges affected patients become exposed to in terms of cost of care, prolonged hospital stays, and complications [24]. An analysis published in the British Medical Journal this past May estimates that medical errors cause over 250,000 deaths each year. Alan M. Jones, É grátis para se registrar e ofertar em trabalhos. Medical errors go beyond just medication errors. Many factors can lead to medication errors. Medical errors are considered as a major threat to patient safety. In addition, the authors emphasised the need for learning and identifying MEs through voluntary and mandatory reporting systems [6]. The collected data were analysed quantitatively using descriptive statistics. A little more than 4,000 surgical errors occur each year. In total, 76.0% of the participants have experienced MEs on a regular basis. The pilot survey also enabled the researcher to make any modification needed and clarify vague questions. Similarly, another study found that MEs such as dosage, wrong descriptions, and dispensation accounted for 47.0% of MEs in the UK [17]. A study conducted in 2014 evaluated PSC in Kuwait and reported that participants (nurses, physicians and administrative staff) rated patient safety at their workplaces highly, with 74.1% reporting no events that compromised patient safety in the last one year [10]. Some of the recommendations included: MEs play a significant role in influencing the safety of patients in Kuwait. Medical errors are of economic importance and can contribute to serious adverse events for patients. The number of respondents who gave a certain response out of the total number of respondents were provided to show the perspectives of the healthcare professionals towards a certain metric. In addition, Table 3 also shows the additional areas where the MEs were likely to be reported including the out-patient department, clinics, during hospitalisation, dietary department, negligence by nurses who do not take care of the patient, pharmacy, and during diagnosis. Finally, we have designed the study tool which was piloted and assessed on face and content validity. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. The literature has widely documented the severity of MEs with a study indicating that such errors largely occur during drug administration and formulation processes [9]. More than 400,000 people die every year in America. The participants confirmed that there are several causes of MEs in healthcare settings which are as a result of miscommunication between medical providers and the patients, poor communication among the staff members such as between the doctors and the pharmacists, workplace fatigue, and carelessness and lack of attention [20]. The study participants confirmed their experience with MEs and noted that common inconsistencies develop during communication, authorisation, and prescribing due to labelling errors and dosage formulation. For instance, a patient may present with an unknown allergic reaction after receiving a new medication. An unintentional act (either of commission or omission) or an act that fails to achieve its planned outcome is another definition for MEs [2]. Descriptive statistics were used to summarise aspects of the data to provide information about the sample as well as the population from which it was drawn [12]. For example, a study reported that one of the common risk factors for MEs is inadequate knowledge and training on prescribing skills for care providers. Compared to published literature, the frequency of MEs appears higher than that reported in the UK and slightly lower than the values reported by Ghanaian public hospitals. Across the global healthcare sector, MEs have been attributed to AEs, increased costs, and overall poor care delivery. Poor communication often results in medical errors. If the patient is fortunate, a medication error will have little to no effect on their wellbeing. This might include an inaccurate or incomplete diagnosis or treatment of a disease, injury, syndrome, behavior, infection, or other ailment. medical errors - Find news stories, facts, pictures and video about medical errors - Page 1 | Newser Drug-related problems due to medication errors are common and have the potential to cause harm. Yearly, medical errors cause $20 billion in excess healthcare insurance claims nationally. The pilot study also assessed the research protocols and recruitment strategies [13]. Combined, these five MEs accounted for 60.3% of all the MEs that were identified by the participants in Kuwait. The questions were grouped under three sections, each exploring a specific theme. By using random sampling the likelihood of bias during the selection of participants was minimised and sampling errors were reduced [12]. In the process, potential errors such as over or under dosage can result when prescribing medicals to patients [21]. The research focus was to investigate the triggers of MEs and strategies that can be adopted and implemented to reduce future occurrences of MEs. To clarify medical errors’ status in Iran, a review was conducted to estimate the accurate prevalence of medical errors. Strategies that can be used to mitigate and prevent potential cases of MEs in Kuwait were also identified. In line with research Objective 1, the data drawn from the present research revealed that the frequency of MEs in Kuwait is high. ... How many things served us yesterday for articles of faith, which today are fables for us? No identifiable personal data was collected during the surveying process. Sarah’s story illustrates the importance of context as she remembers why she did not record the medication she had administered to Mrs. May. Other researchers have documented increased mortality attributed to high severity MEs [25]. Therefore, there might be a risk of respondents refusing to participate due to guilt and fear as well as uncertainty about confidentiality. He died at a hospital that had people brave enough to face me, bold enough to take responsibility, compassionate enough to explain. The pilot study aimed to test the face and content validity of the questionnaire. Medical Errors May Increase Around Daylight Saving Time in the Spring After the loss of an hour from daylight savings, the number of human mistakes increased by … Share. Medical mistakes are the third leading cause of death in the United States. Medical Errors: Telling Your Story . The following initiatives were also noted by fewer participants; encourage communication between all departments, emphasising that every healthcare worker should be responsible, encourage reporting and discussing possible errors, creation of further hospitals to reduce patient populations per hospital. 5 Patient harm from medical … As such, the severity of MEs ranged from often (60.5%), rare (15.3%), less often (11.5%) to never (12.7%). While another study explored PSC in Kuwait among hospital staff [11], Ghobashi and colleagues only investigated awareness among primary healthcare providers about PSC [10]. Missed diagnoses or injuries from medication are common in outpatient settings. Nonetheless, the pharmacists comprise the majority of HCPs in addressing the shortage of care providers in most countries; both in the public and private medical facilities hence there were more pharmacists among respondents. But if the patient is less fortunate, a medication error can lead to significant harm, even death. Medical errors in the emergency department (ED) occur frequently. If you do make an error, document what the patient received and report it immediately to the patient’s physician and your employer. Past literature studies have shown that there are feelings of shame, guilt and panic after the occurrence of MEs among HCPs [14]. There have been very few academic studies in this field in Kuwait [10, 11]. We wish to acknowledge the Kuwait Ministry of Health for ethical approval and support in facilitating conduction of the research study. Moreover, MEs prevention is important in promoting patient safety culture (PSC) and eliminating financial burdens on healthcare institutions, and families of the affected patients [4, 8]. Common consequences faced by physicians after medication errors can include civil actions, criminal charges, and medical board discipline. Patients interacting with healthcare organizations have an expectation of safety. Some of the initiatives that can be adapted to reduce MEs include encouraging employees to embrace incident reporting, consulting with more qualified and experienced colleagues during uncertain procedures, educating patients on the use and effect of different medications, and collaborating with colleagues to improve service delivery. In m… The frequency of medical errors in Kuwait was found to be high at 60.3% ranging from incidences of prolonged hospital stays (32.9%), adverse events and life-threatening complications (32.3%), and fatalities (20.9%). A study conducted in 2014 found that lack of compliance among patients regarding administration and prescription guidelines further increased the risk of MEs [5]. Learning medical terminology is not that easy. Other strategies (1.3%) such as reaching out to the patient before taking the medication and engaging with colleagues to improve service delivery were used to reduce potential MEs. (iii) encourage reporting by the workers and other stakeholders, and (iv) reducing workload or increasing the number of HCPs to reduce workload and give employee flexible work schedules that help them achieve work-life balance. We asked participants to identify possible mitigation strategies that could be used to address the potential MEs identified. In addition, other participants (20.8%) also expressed that patients were to blame for MEs, while other respondents indicated that various departments were responsible for MEs (7.6%). The situation is worsened by poor coordination and lack of training programs to educate HCPs on the importance of reporting MEs once they occur [26]. Tang and colleagues advocate for the need to have in place pro-active management processes aimed at reducing MEs in healthcare facilities [29]. In Kuwait, there is a paucity literature detailing the causes, forms, and risks of medical errors in their state-funded healthcare facilities. Medical errors are considered as a major threat to patient safety. Exactly how many, we can’t say, because there is no national registry for injuries or deaths caused by medical errors. Further assessment of the tool construct validity and reliability is required in the future. However, 38.6% of the participants expressed that the state of workplace relationships does not affect or compromise service delivery. Medical errors are of economic importance and can contribute to serious adverse events for patients. Professional communication among health-care providers is a complex topic that is analogous to critical communications, as practiced by other high-risk professions. A total of 44.6% of respondents confirmed that they had encountered potential MEs while 55.4% had not experienced any MEs in their practice. If good teamwork does not exist, however, r… The researcher informed the participants that their confidentiality would be guaranteed, data obtained anonymously. This study aimed to explore medical errors, their causes and preventive strategies in a Kuwait tertiary hospital based on the perceptions and experience of a cross-section of healthcare professionals using a questionnaire with 27 open (n = 10) and closed (n = 17) questions. In this case, the allergic reaction is the unexpected or unplanned outcome, yet it cannot be holistically argued that the outcome is attributable to ME. Ali and colleagues found that when assessing PSC in Kuwait, the hospital management lacked critical unit-level systems such as non-punitive responses, open communication channels, and staffing important to improving patient safety [11]. If this is true, then medical errors are the third most common cause of death in the United States. In addition to causing loss of public confidence, these events have increased patient morbidity and mortality and raised healthcare costs (Pham et al., 2012). It is argued that often, there are circumstances beyond the control of the healthcare provider that influence patient outcomes [3]. In surgeons, medical errors were negatively related to engagement (R 2 = 0.210, p = 0.004), while teamwork and depersonalization were the only predictive factors of frequency of medical errors, in both pediatricians and internists (R 2 = 0.306 p < 0.001). According to a 2000 report citing UK medical defence organizations, 1 25% of all litigation claims in general medical practice were due to medication errors and involved the following errors: prescribing and dispensing errors (including a wrong, contraindicated or unlicensed drug, a wrong dosage, or wrong administration); The tool for data collection was a self-administered open and closed-ended questionnaire (S1 Appendix). A recent report on healthcare quality advocated the need for a thorough approach to MEs in the Middle East [6]. Had that treatment continued, she might have lived for years. However, the respondents indicated that they did not compromise patient safety to get more work done implying that the perception of patient safety among medical workers was high. In addition, 50.7% of the participants noted that encouraging workers and auditors to report MEs was also an important avenue that healthcare institutions can use to reduce MEs. Sleep deprivation in physicians is linked to serious medical errors that result in patient harm. July 08, 2019 - More than 30 percent of all EHR-related patient harm events cited in malpractice claims involve medication errors, according to … A Trail of Medical Errors Ends in Grief, But No Answers. Stubbs and colleagues also advocate the use of technology systems to increase patient safety through computerisation where errors of prescription, medications, synchronising data between departments, and information technology can be used to improve communication and reduce potential bias resulting from mislabelling, wrong spellings, and poor handwriting [30]. The survey sought to identify the most common causes of MEs. Most malpractice claims in hospitals are related to … Nevertheless, the current study design allowed accessing a large sample of respondents and suited the present study objectives. A Doctor Confronts Medical Errors — And Systemic Flaws That Create Mistakes : Shots - Health News Dr. Danielle Ofri says medical errors are more common than most people realize: "If … However, the use of automation and other system improvement strategies aimed at reducing potential MEs will depend on addressing a number of hurdles first. Medical errors are the third leading cause of death in the US, just behind heart disease (#1) and cancer (#2). Frequencies and percentages were used to summarise the data. A study conducted in 2009 found similar trends in a state hospital in Ghana where prescribing errors (e.g. As many as 80 percent of medical bills contain at least one error. Such an approach would help deal with MEs through the analysis to find out the cause of the problem and establish a system for not repeating this error. Other potential approaches (as expressed by 5.3% of the participants) that can be used by health institutions to mitigate against MEs include (i) encouraging communication between departments as well as and making people accept the fact that discussing errors to correct them will benefit the overall outcome for patients. The common types of errors identified were prescribing errors, nursing errors, pharmacist errors, and laboratory or diagnostic errors. For example, the HCPs confirmed that they often encountered MEs in almost every department both in the outpatient and inpatient facilities. It’s estimated that 7,000 to 9,000 patients die every year from medication errors. Medical negligence evolves from errors of commission to errors of omission: the malpractice crisis of the 1970s. By most accounts, frank errors, such as mixing up heparin and Levophed, were uncommon, but the cascading effects of an overstretched system often led to medical care that was less than ideal. As the nurse ushered them out of the room, she assured the patient and her daughter that she would discuss the c… Moreover, the additional hurdles that participants identified as alternative hindrances to reporting of MEs include: The fear ME reports will be used to blame other departments, Lack of knowledge about the need and importance to write incident reports, People feel discouraged when they report an error, and they do not see an end result. The most significant risks associated with this research are linked to the aspects of confidentiality. PLoS ONE 14(5): The summaries derived from the descriptive analysis were presented in charts and tables. In conclusion, the findings of this study are in line with the postulated hypothesis in that healthcare professionals’ perspectives on MEs is crucial in identifying important insights about MEs and how the identified errors can be addressed. After that, her family couldn't get accountability. 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