Diagnostic error prevention & patient safety

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Contents

Last Update

  • Updated.jpg 26 October 2016

Introduction

See also Clinical librarianship | Evidence-based health care | Knowledge translation and synthesis | Point of care evaluation criteria

"...As it turns out, 138,000 — or one in every 18 — patients admitted to a Canadian hospital in 2014-15 suffered some kind of harmful event that could potentially have been prevented, from getting the wrong drug to developing an infection, a report released Wednesday has found...."Canadian Patient Safety Institute, 2016

Diagnostic error is defined as "...a mistake in therapeutic judgment regarding the etiology (cause) of a medical problem, illness...or its treatment". Diagnostic errors are the leading cause of medical malpractice claims and cause untold deaths annually around the world. One in every ten diagnoses is wrong and one in every thousand ambulatory diagnostic encounters result in harm. Diagnostic error may result from a number of factors; medical error is a major threat to patient safety. According to the Canadian Patient Safety Institute (CPSI) (Institut canadien pour la sécurité des patients), patient safety may be defined as "...a healthcare discipline that emphasizes the reporting, analysis, and prevention of medical errors that lead to adverse healthcare events, and a compromise to patient safety".

Some patient safety-related vocabulary includes: medical error which is the failure of planned actions to be completed as intended by the physician or care team (this includes the use of a plan ill-suited to achieve its aims); adverse events which refers to injury (or harm) that results from the provision of medical care (and which is not a part of the natural disease process). In some dire cases, malpractice lawsuits result from medical and diagnostic errors.

Examples of diagnostic error

According to Leape (1993), medical errors can be classified according to four major categories: “diagnostic”, “treatment”, “prevention” and “others”
  • Errors in the prescribing, transcribing, dispensing, administering, and monitoring of medications and vaccines
  • Wrong drug, wrong strength, or wrong dose errors
  • Drug — drug interactions
  • Confusion over look-alike/sound-alike drugs or similar packaging
  • Wrong route of administration; calculation or preparation errors
  • Misuse of medical technology or equipment
  • Other major problems related to healthcare system error include wrong-site surgeries, hospital acquired infections, falls.

Adverse events

Adverse events run the gamut from improper transfusions, surgical injuries and wrong-site surgery, suicides, restraint-related injuries or death, falls, burns, pressure ulcers, and mistaken patient identities. High error rates with serious consequences are more likely to occur in intensive care units, operating rooms and emergency departments in the hospital setting.

Hospital Harm Framework

See Hospital Harm Framework http://www.nhlc-cnls.ca/assets/2016%20Ottawa/DSilva_Measuring%20patient%20safety%20in%20Canadian%20hospitals.pdf

Principles of patient safety

Patient safety is central to quality health care, and is reflected in the Hippocratic oath: Primum non nocere or First do no harm. Roman physician Galen, like Hippocrates his Greek counterpart, was chiefly led by this maxim. Similarly, this quote is often used to illustrate the long history of patient safety in medicine: "...as to disease make a habit of two things — to help, or at least do no harm. The art consists in three things - the disease, the patient, and the physician."

Diagnostic errors threaten the safety of patients, and they occur every day in hospitals and clinics worldwide. The key to patient safety is the prevention of injuries or death through early responses to a possible or emerging problem. An improvement in patient safety is possible through the creation of a culture of trust, honesty, integrity and open communication between clinicians and patients. In order to make advances in patient safety, a body of scientific knowledge is required as well as the infrastructure to support its development. Patient involvement in continuous learning and constant communication of information will ultimately improve patient safety.

Key websites

Health librarians' roles in patient safety

In 2013, the Medical Library Association held a webcast Partnering to Prevent Diagnostic Error: Librarians on the Inside Track for its members to explain what diagnostic errors are as a subset of patient safety. The webcast discussed collaborative roles for health librarians in the prevention of error from solo to larger medical libraries and using activities to collaborate on error awareness and reduction. The outcome was to emphasize the unique position of health librarians in their institutions to participate and collaborate with clinicians who may be working to address Dx error.

Zipperer (2004) writes: "...Librarians could improve the safety of medical care through greater participation in patient safety initiatives. A librarian's expertise in accessing the evidence base could enhance the safety and appropriateness of care in a clinical environment. In addition, librarians could apply specific technical knowledge management skills to medicine. To realize improvements from these skill sets, healthcare leaders must consider ways of working with librarians to enhance patient safety..."

References

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