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MANAGING MEDICAL ERRORS, LEARNING FROM OTHER INDUSTRIES

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BY KEITH E. CHEW

Every process that involves humans is vulnerable to mistakes. Every industry experiences errors. Do you wonder how this impacts our daily lives? Here are a few examples:

• 90% of cyber-attacks are caused by a human initiated error • Human-initiated accidents cause 70% of all data center outages • Boeing says that 80% of all airplane accidents are the result of human error • 250,000 deaths each year are caused by human medical error

These statistics are eye-opening and naturally lead to the question, how can we mitigate human error?

HEALTH CARE IS AN INDUSTRY OF HUMANS

Unlike technology-driven industries, health care relies on humans and their expertise to provide lifesaving medical care. According to the 2019 American Community Survey (ACS), during that year there were 22 million workers in the health care industry, and this number grows every year. With health care being a high human touch industry, it’s no surprise that errors occur.

Why do errors happen? There are many things that increase the risk of error, workload, time of day, being hungry, local distractions and noise, time pressures, and clinical skill level can all play a role. As health care professionals, it’s incumbent on each of us to look outside of our immediate work environment and learn from other industries and experts.

Medical errors are the third leading cause of death and account for nearly 250,000 fatalities annually. Errors can occur in any health care setting and at any point in the care process. The U.S. health care system is stretched thin; health care professionals are stressed and facing burnout. Providing patients with the best

possible care is always the goal but can be challenging, given the current environment.

Preventable medical errors affect up to 7 million patients and cost over $20 billion each year, but the cost is more than just financial. Medical errors compromise patient care and can lead to poor patient outcomes and even death.

DEFINING MEDICAL ERROR

Medical errors are preventable, adverse effects of receiving medical care. While there is some debate around the definition of a medical error vs. a discrepancy, two major types of errors should be noted: • Errors of omission occur as a result of actions not taken. An example would be failing to prescribe a proven medication with significant benefits for an eligible patient. • Errors of commission occur as a result of incorrect action taken. An example is prescribing a medication for a patient with a known allergy to the drug.

An RSNA journal article highlights the significant challenge of diagnostic error, estimating the rate of missed, incorrect, or delayed diagnoses to be as high as 10% to 15%. It’s estimated that one billion radiologic examinations were performed worldwide in 2015, and most were reviewed and interpreted by a radiologist. Given these numbers and the current state of the U.S. health care system, some errors are inevitable. We find different ways to reduce and address errors as we look across industries. Strategies include checklists, confidential error reporting systems, education and peer learning programs. For example, the airline industry has a reporting system similar to the Patient Safety Organization (PSO) program. Technology, such as artificial intelligence, is used by the credit card industry to rapidly review a large volume of tractions that would not be manageable by humans alone. The energy industry uses a peer review process to understand and learn from human mistakes. In this five-part series, we’ll explore error mitigation strategies that have been proven successful in other industries. Then, looking through the health care lens, we’ll assess the role artificial intelligence can play in equipping health care professionals with tools that improve accuracy and function as a safety net.

Health systems can leverage cross-industry learnings by asking a few questions: • What other industries deal with errors that could result in life-threatening situations? • How is technology helping different industries improve accuracy and manage large volumes of data? • What role does education play in managing medical errors?

Join us next month as the series continues and we look to the credit card industry for ways to manage errors. •

Keith E. Chew, MHA, CMPE, FRBMA, is a principal with Consulting with Integrity.

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