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Distance Education -> Prevention of Medical Errors for the Massage Therapist -> Chapter: 01
Definition of Medical Error
Medical errors are one of the leading causes of injury and death in our Nation’s healthcare industry. What are medical errors? A medical error happens when a part of a medical treatment plan does not work correctly, or is misinterpreted, resulting in injury or death. Or quite possibly, the incorrect plan was used in the first place. The Institute of Medicine (IOM) specifically defines a medical error as “the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim.” The report goes on to say, “ Errors depend on two kinds of failures: either the correct action does not proceed as intended (an error of execution) or the original intended action is not correct (an error of planning)[1]. Medical errors can happen at any point in the process of healthcare for the patient. The points in the process of healthcare are diagnosis, anytime during treatment or surgery, as well as preventive care.
Not all medical errors result in injury or death. The IOM goes on to describe a medical error as an adverse event, specifically, “ an injury caused by medical management (intervention) rather than by the underlying disease or condition of the patient. ”All adverse events result from medical management, and not all are preventable. This means that not all adverse events are attributable to errors. For example, an adverse event would be noted if a patient comes down with pneumonia postoperatively and dies. If a case review determines the patient died from exposure to pneumonia as a result of poorly cleaned instruments or poor hand washing on the caregiver’s part, then the adverse event qualifies as a medical error. In this case, the adverse event could have been prevented, therefore a medical error occurred in the postoperative care. If the case review determines the patient died as a result of a difficult surgery and recovery, then the adverse event that resulted would not qualify as a medical error.
Analysis of adverse events like the one stated above is very important to healthcare. Adverse events resulting in serious injury or death, as well as those that do not end in patient harm should always elicit a case review. The review helps to assess the likelihood of a similar event occurring in the future, and whether or not it can be prevented. Medical errors of all types can be prevented by improving the quality of health care in the system, through improving the quality of the delivery process.
In 1999, The Institute of Medicine recently published a report, “To Err is Human Building a Safer Health Care System” that estimates that approximately 44,000 to 98,000 people in U.S. hospitals die each year as a result of medical errors.[3]
1 Kohn, Linda T., Corrigan, Janet M., Donaldson, Molla S., Editors, To Err Is Human Building a Safer Health System, Washington D. C., National Academy Press, 1999
2 Deming, W. Edwards, Out of the Crisis, Cambridge: Massachusetts Institute of Technology, Center for Advanced Engineering Study. 1993.
3 Kohn, Linda T., Corrigan, Janet M., Donaldson, Molla S., Editors, To Err Is Human Building a Safer Health System, Washington D. C., National Academy Press, 1999
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