Literature Review of Medical Errors and Misdiagnosis

According to Kaiser attention to medical errors escalated over five years ago with the release of a study from the Institute of Medicine (IOM), which found that between 44,000 and 98,000 Americans die each year in U.S. hospitals due to preventable medical errors (Kaiseredu, 2010). Hospital errors are the fifth and eighth leading cause of death, killing more Americans than breast cancer, traffic accidents or AIDS. Serious medication errors occur in the cases of five to 10% of patients admitted to hospitals. These numbers may understate the problem because they do not include preventable deaths due to medical treatments outside of hospitals (kaiseredu, 2010).

Several studies since the IOM report in 1999 validated the prevalence of medical errors. A nation-wide study conducted in 2002 found that 35% of physician respondents and 42% of the public respondents had themselves or had family members who experienced some type of medical error (Blendon et al., 2002). In 2004 the Department of family medicine at the University of Cincinnati in Ohio conducted a retrospective chart review and analyzed 351 family physician patient visits. Within these visits 117 errors or preventable adverse events occurred during 83 (23.6%) of the visits. More than one error was identified in 22 of the 83 visits.

Another study that focused on intensive care unit (ICU) experiences of adult patients requiring at least 48 hours of intensive care revealed that 56.2% of reported adverse events involved care-givers who worked in the ICU. Of these adverse events, 9% led to additional life-sustaining treatments, and 3% of the deaths found may have been attributable to medical error (Osmonet al., 2004). A recent study of primary care encounters using 38 in-depth anonymous interviews found that 23% of the physical harms included worsening medical conditions, pain, bruising, and adverse drug reactions (Kuzel et al., 2004).

According to Bogdanich (2010), the Department of Veteran Affairs (VA) was fined by the Nuclear Regulatory commission due to a serious medical error that occurred at one of their facilities. The Nuclear Regulatory Commission announced its second-largest fine in the amount of $227,500 after finding that the veterans hospital in Philadelphia had caused an “unprecedented number” of radiation errors in treating prostate cancer patients (Bogdanich, 2010). Bogdanich stated that theses same errors occurred 15 years ago and since then preventative measures were established so these errors would not occur. Federal investigators said that VA hospitals made significant errors, misplacing radioactive seeds, in 97 of 116 procedures involving patients with prostate cancer from 2002 to 2008. The regulatory commission’s largest fine against a medical provider was 15 years ago and totaled $280,000. That case also involved radiation errors (Bogdanich, 2010).

During 1997 the National Patient Safety foundation conducted a phone survey to capture patient opinions about medical mistakes. The findings showed that 42% of people believed they had personally experienced a medical mistake. In these cases, the error affected them personally (33%), a relative (48%), or a friend (19%) (Wrongdiagnosis, 2010). Patients that were given the survey have experienced the following medical errors:

• Misdiagnosis (40%),
• Medication error (28%),
• Medical procedure error (22%),
• Administrative error (4%),
• Communication error (2%),
• Incorrect laboratory results (2%),
• Equipment malfunction (1%), and
• Other error (7%).

(Wrongdiagnosis, 2010)

According to J. E. Wilcoxson, Chief Prosthetic & Sensory Aids at the VA Medical center Columbia S.C. (personal communication July 26, 2010) patient safety should be the number one concern for health care organizations. Health care managers are held accountable for ensuring that patients are provided with quality care. They are also accountable for patients that are injured or die due to a provider’s medical error. The health care industries along with scientific researchers have developed tools in which the quality of care can be measured. Organizations can use these tools to determine if effective care is being provided. Once they have determined the level of care they are providing, they can educate providers on what they are doing both wrong and right. The most common method used to determine the quality of care, is through the use of surveys. Health care organizations can provide staff and patients with surveys to determine what areas the organization can improve and sustain. These surveys will not be provided, to every patient the provider has treated but only a selected few will be surveyed.

In 2007 Cohen published a book that stated “quality measurement in the healthcare industry requires a large amount of resources and funding”. According to this book researchers will most likely use methods that have worked before and have provide them with data; they could use to enhance the level of care the organization is providing. Cohen believes healthcare researchers are constantly trying to find ways in which they can completely eliminate medical errors. During this research it was determined that due to the continuous cycle of experienced providers leaving and new providers being hired, medical errors in many cases will never be eliminated. Cohen believes in the theory that health care organizations can implement the necessary control measures to ensure that patients are not misdiagnosed or the wrong limb is not amputated (Cohen, 2007).

Cohens publication also focused on how healthcare organizations can decrease medical errors by establishing a continuous quality improvement plan. This plan will call for the development of a multidisciplinary team to research and investigate the causes of medical errors. According to the Department of Veteran Affairs, medical centers use a continuous quality improvement model developed by the Joint Commission to reduce the number or medical mistakes made by providers. According to an interview conducted with staff at the William Jenning Bryan Dorn VA Medical Center in Columbia SC, Joint Commission surveys all the Veteran Affairs Medical centers to see whether their staff is following the medical policies and regulations in providing quality care by reducing medical errors.

In 2010 Joint Commission established policies regarding how health care organizations will report and handle sentinel events. A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase, “or the risk thereof” includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome. Such events are called “sentinel” because they signal the need for immediate investigation and response (Jointcommission, 2010).

A study conducted in June 2010 at the University of California in San Francisco analyzed 62,338,584 U.S death certificates for the period 1979 to 2006, ultimately focusing on 244,388 deaths linked to medication areas, reports the Los Angeles Times. The findings revealed an average increase of 10 percent in medication-linked deaths in July in counties with teaching hospitals, but none in other counties–with the most deaths in areas with the most teaching hospitals (Fiore, 2010).