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According to the report of the IOM (Institute of Medicine) as published in “To Err is Human” medical errors is common in our hospitals. There are at least 44,000 deaths per years from medical errors. Most experts believe that these medical errors are the result of the whole medical care system, not the individual health care provider.
“Errors occurred most frequently in communication, postoperative monitoring and care, and diagnosis, with errors in postoperative care and diagnosis having the highest likelihood of resulting in an adverse outcome.”
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J Pediatr Surg. 2003 Sep;38(9):1361-5.
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Incidence of medical error and adverse outcomes on a pediatric general surgery service.
Proctor ML, Pastore J, Gerstle JT, Langer JC.
Background/purpose: The Institute of Medicine has identified medical error as a leading cause of death and injury, with deaths resulting from medical error exceeding those caused by motor vehicle collisions, breast cancer, or AIDS. The authors examined the incidence and sources of medical error in relation to adverse events on a pediatric general surgery service. Methods: All intensive care unit (ICU) and ward admissions to 2 staff pediatric general surgeons during a 1-month period were identified prospectively and in-patient care was reviewed daily by a 3-person panel consisting of a staff surgeon, a surgical fellow, and a nonmedical observer. Medical errors, identified through daily patient encounters, nursing rounds, medical rounds, and chart examinations, were evaluated based on type, hospital setting, personnel involved, and outcome. Adverse outcomes were evaluated based on type and contributing factors. Results: Our study group included 64 patients. A total of 108 errors were identified; 28% of these errors resulted in adverse outcomes. One or more medical errors were identified in the care of two thirds of patients (43 of 64), with medical error contributing to adverse outcomes in one third of patients (21 of 64). Errors occurred most frequently in communication, postoperative monitoring and care, and diagnosis, with errors in postoperative care and diagnosis having the highest likelihood of resulting in an adverse outcome. Seventy-four adverse outcomes were identified in 31 patients; 35 (47%) of these outcomes, occurring in 21 patients, were attributable to medical error. The most common adverse outcomes identified were additional nonoperative procedures, of which, 92% resulted from medical error. There were no deaths. Conclusions:
Medical error occurs in more than one half of hospital admissions on a general pediatric surgery service and contributes to a substantial number of adverse outcomes.
Example of Diagnostic Error
False Positive Biopsy
Prescription Error
Systems Errors
Flying Infusion Pump
Printed Prescription
Medical Errors a National Problem
Compunding Medication Error
Pediatric Surgery Errors
Leo Leonidas, MD, FAAP
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