How can so many medical errors not only happen but persist in the healthcare system over time?

First, let’s put the numbers into perspective.  In 1999

• 44,000 – 98,000 deaths per years from medical errors
• Medical errors cost $17B – $29B each year, of which health care costs represent over $8.5B – $14.5B
• 13.4% of GDP spent on healthcare (Source: OECD) 
• US GDP = $9.301 T (Source: World Bank)
• Annual deaths: 2,411,000 (Source: US Census)
• So in 1999 errors committed in the health care system amounted to 

• 1.8% - 4.0% of US deaths 
• 0.2% - 0.3% of US GDP  
• 0.7% - 1.2% of US Healthcare Spending 

The numbers show that while errors in the healthcare industry seem large in absolute terms, they are very small relative to total activity in the US.  Nonetheless, the number of errors in the health care system should certainly be reduced, assuming they can be done so cost effectively (that is, at an annual cost of less than $17B – $29B).

First, let’s take a look at the sources of errors within the healthcare system.

Source of Healthcare System Errors

James Reason, author of Human Error and “Human Error: Models and Management” asserts that within the healthcare system “nearly all adverse events involve a combination of” active failures and latent conditions.

Active failures are the unsafe acts committed by people who are in direct contact with the patient or system … [while] latent conditions are the inevitable “resident pathogens” within the system.

According to Reason, when thinking about the occurrence of errors, their reporting, and their consequences, most people tend to take a person approach.

The person approach focuses on the unsafe acts—errors and procedural violations—of people …

It views these unsafe acts as arising primarily from aberrant mental processes such as forgetfulness, inattention, poor motivation, carelessness, negligence, and recklessness…

Followers of this approach tend to treat errors as moral issues, assuming that bad things happen to bad people …

Blaming individuals is emotionally more satisfying than targeting institutions… [Furthermore] [s]eeking as far as possible to uncouple a person’s unsafe acts from any institutional responsibility is clearly in the interests of managers. It is also legally more convenient …

The alternative is the system approach to errors.

The basic premise in the system approach is that humans are fallible and errors are to be expected, even in the best organisations…

[Under this approach, errors have] their origins in “upstream” systemic factors. These include recurrent error traps in the workplace and the organisational processes that give rise to them…

When an adverse event occurs, the important issue is not who blundered, but how and why the defences failed.

Reason defines high reliability organizations as

systems operating in hazardous conditions that have fewer than their fair share of adverse events.

High reliability organisations are the prime examples of the system approach. They anticipate the worst and equip themselves to deal with it at all levels of the organization … For these organisations, the pursuit of safety is … about making the system as robust as is practicable in the face of its human and operational hazards. High reliability organisations are not immune to adverse events, but they have learnt the knack of converting these occasional setbacks into enhanced resilience of the system.

Another scholar, Mark R. Chassin, classifies healthcare errors into three categories: overuse, underuse, and misuse, and he notes that “The majority of these problems are … frighteningly common, often predictable, and frequently preventable.”

Overuse

Providing a health service when its risk of harm exceeds its potential benefit constitutes overuse. Perhaps the most frequently cited causative factor in discussions of overuse is fee-for-service (FFS) payment…

A less well appreciated, but probably more important, factor leading to overuse is enthusiasm ––the degree to which physicians and other purveyors of specific health services become passionate advocates for the services they provide, instead of objective caregivers, whose recommendations are governed strictly by scientific evidence of efficacy…

Another cause of overuse is related to the way patient referrals to specialists frequently occur… Specialists are under some pressure in this situation to function like technicians: that is, to perform the requested procedure, instead of conducting a thorough and independent assessment of the necessity for the intervention…

Various social and cultural factors add to the complex reasons for overuse. Americans are activists. We expect that our doctors will "do something" when we present with symptoms of illness…

Related to this cultural propensity is our national infatuation with technology. … patients expect that the latest machine or pill or surgical procedure will be used to treat their conditions…

Reinforcing these social and cultural proclivities is physicians' fear of the malpractice lawsuit.

Underuse

Failing to provide an effective service when it would have produced favorable outcomes constitutes underuse…

Problems of underuse result from … factors, including financial barriers such as lack of insurance, the imposition of copayments and deductibles, and benefit packages that do not, for example, cover preventive care…

Another important, but less often recognized, reason for underuse is the rapid and recent accumulation of an enormous amount of information about what works and what does not to produce good outcomes in health care…

Misuse

Avoidable complications of appropriate health care define misuse…

[W]hen systematic analyses of preventable complications have been performed, they revealed that faulty systems of care are responsible for error more often than individuals…

Like many underuse problems, large numbers of preventable complications in health care appear to arise from our construction of health care delivery systems. We have created systems that depend upon idealized standards of performance that require individual physicians, nurses, and pharmacists to perform tasks at levels of perfection that cannot be achieved by human beings.

Nest, let’s examine why healthcare personnel might be reluctant to report errors.

Barriers to Error Reporting

It turns out there are a host of reasons why healthcare personnel would be reluctant to report errors that occur while providing patient care. The primary barriers to reporting are fear of punishment, fear of liability, and/or fear of loss of reputation by healthcare personnel.  For example, one study (Joshi, et al) reported

In a survey of 644 healthcare professionals, conducted in October 2000, the reasons cited include loss of reputation (> 90%), the fear of losing their job (90%), and loss of market share, loss of accreditation, and liability concerns (> 80%).

Another study (Tuttle, et al) that established a reporting system in a hospital noted that the majority of errors were reported by nurses (69% of errors reported in the study), followed by administrators or managers (13% of errors).  The authors noted that “The infrequency of physician reporting [2% of errors] is probably due to a number of reasons based on cultural factors, time factors, fear factors, or lack of awareness.”

These and other studies mention other barriers, such as

• Lack of an established reporting process;
• A burdensome reporting process;
• Lack of a definition of error – do reporting events include only those that lead to serious patient harm, or do they also include near misses;
• “Lack of true leadership in medical error prevention”.

The existence of such barriers means that in order to get the healthcare personnel to report errors, these barriers to reporting would have to be overcome.

Characteristics of an Ideal Healthcare Industry Error Reporting System

The Tuttle, et al, study summarize the important characteristics of an effective error reporting system:

Characteristics considered to be important for a successful voluntary reporting program include a non-punitive or safe environment, simplicity in reporting, and timely and valuable feedback.

In this case, feedback comes in two forms: (1) a periodic newsletter circulated among industry personnel describing some of the more common errors, together with (2) an analysis of “trends of events, potential contributing factors, and the systems based, human based, or patient based solutions ultimately to improve safety.”

The study also notes that

Continued education and guidance is critical to improving the reliability of coding adverse events. Equally important, however, is continued education around the science of patient safety…

The Joshi et al study noted that a healthcare provider’s commitment to patient safety

depended on many factors: the willingness of management and staff to be trained and educated; the completion of an organizational self-assessment to see where they stood; and an openness to receiving communications throughout the implementation process on the definition of an error, why it’s important to report, how to improve reporting, and the cultural and environmental issues that surround error reporting. There had to be willingness by both the management and staff to understand that this was a continuous learning experience that would necessitate their ongoing support and participation. The great challenge was focused on how to execute, communicate, educate, and train effectively; how to keep patient safety a priority of the organization; and how to sustain this movement.

The Risk Prevention and Management (RPM) System established in the Joshi, et al study consisted of

five main components: anonymous reporting, incident reporting, near miss reporting, interactive education, and a risk analyzer. The usefulness of the system relies on the simplicity of data entry, the ability to collect and store a large volume of data in a secure environment, and breadth of analysis and ad hoc reporting available to a site manager.

Finally, the Institute for Safe Medication Practices adds that

The success of current voluntary reporting systems also stems from the trust and respect that has typically developed between reporters and recipients who use the information to improve patient safety across the nation. Reporting is perceived to have immense value when those who report an error or potentially hazardous situation can readily see that the information is swiftly acted upon and used confidentially and proactively to develop and publish safe practice recommendations that can prevent errors. Additionally, many voluntary systems are considered more credible because of their autonomy and because they operate independently without reliance upon or relationship to regulatory and accrediting bodies or other health care community stakeholders. Thus, the analysis of the information can provide new knowledge about patient safety, without conflict of interest or pressure from other political, economic, or marketplace forces.

Perhaps most important, the success of current voluntary reporting systems stems from their non-punitive, system-based approach to error reduction.