TABLE OF CONTENTS
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 MEDICAL ERRORS AND ETHICS

bullet   Learning Objectives
bullet   Introduction
bullet   To Error is Human: The Report
bullet   Fact Sheet Improving Health Care Quality
 bullet   Errors in Health Care: A Leading Cause of Death and Injury
bullet   Why Do Errors Happen?
bullet   Root Cause Analysis
bullet   Theory Behind RCA 
bullet   JCAHO on RCA
bullet   Sentinel Event Glossary of Terms
bullet   References
bullet   EXAM Questions 1-20
     Please note: There are” two” exams

MEDICAL ETHICS IN HEALTHCARE

bullet   Learning Objectives 
bullet   Introduction
bullet   History and Background

  • Ethics vs. Laws
  • The Evolution of Medical Ethics in the United States
  • The World View

bullet   Deciding Ethical Questions
     The Questions
     1. Is it legal?
     2. Is it balanced?
     3. How will it make me feel about myself?
     4. Have my peers determined and published a standard of behavior?
bullet   Contemporary Issues
    The Rise of Bioethics
    Ethical Questions in the Use of Implants
    Cochlear Implants
    Transplants
    The Genome Project
    Reproductive Medicine
    Life and Death Decisions
bullet   How much does the doctor tell you?
    Respect for Persons
    Autonomy
    Truth-telling
    Confidentiality
    Fidelity
    Beneficence
    Nonmaleficence
    Justice
bullet   Economic Considerations
bullet   Ethics and Managed Care
bullet   Conclusion
bullet   References

bullet   Exam Questions 21-40

 

MEDICAL ERRORS

bullet   Learning Objectives

Upon successful completion of this course, you will be able to:

·        You will be able to explain the significance of the To Error is Human Report, and identify its highlights

·         You will be able to list and discuss key steps that can be taken in the Improving of Health Care Quality

·         You will be able to discuss the scope of the problem of medical errors and discuss how they have become a leading cause of death and injury

·         You will be able to explain some of the reasons why errors happen, and what can be done to minimize their occurrence

·         You will be able to discuss what types of errors can occur and where they tend to occur

·         You will be able to explain what is meant by “root cause analysis” and identify the key steps in conducting that analysis

·         You will be able to explain the JCAHO’s role in reducing medical errors and identify some of the key steps they have taken to accomplish that reduction

bullet   Introduction

Most Americans have grown up having the utmost respect for the medical profession and what it has accomplished over the decades. The family doctor who could fix anything became a fixture in our society. If “doc” said you needed something, then that is what you got. People not only didn’t worry about the their healthcare, they didn’t think about it! The physician became almost "infallible" in his or her opinions or actions. It was almost like the situation seen in the film "The Wizard of Oz." What the Wizard ordered was to be done. The system seemed to work just fine. Then came along Dorothy and her darling doggie Toto.

During their visit to the Wizard’s place of wizardry, Toto's curiosity drove him to pull back the curtain, revealing the Wizard as just an ordinary, albeit educated, man whose views and opinions were not always infallible. In the case of the medical profession, the pulling back of “the curtain” has not been such a rapid and shocking event. It has taken place over time.

bullet   To Error is Human: The Report

The exposing of flaws in our health care system began in the media. Sensational medical errors were splattered all over the popular media, and eventually healthcare organizations and government agencies began to investigate. The results of these investigations, as reported in the Executive Summary of an Institute of Medicine report entitled "To Err Is Human: Building a Safer Health System" (2000) proved to be just as shocking as Toto's pulling back of the curtain:

It was reported that the knowledgeable health reporter for the Boston Globe, Betsy Lehman, died from an overdose during chemotherapy. Willie King had the wrong leg amputated. Ben Kolb was eight years old when he died during ''minor" surgery due to a drug mix-up.

These horrific cases that make the headlines are just the tip of the iceberg. Two large studies, one conducted in Colorado and Utah and the other in New York, found that adverse events occurred in 2.9 and 3.7 percent of hospitalizations, respectively. In Colorado and Utah hospitals, 6.6 percent of adverse events led to death, as compared with 13.6 percent in New York hospitals. In both of these studies, over half of these adverse events resulted from medical errors and could have been prevented.

When extrapolated to the over 33.6 million admissions to U.S. hospitals in 1997, the results of the study in Colorado and Utah imply that at least 44,000 Americans die each year as a result of medical errors.3 The results of the New York Study suggest the number may be as high as 98,000. Even when using the lower estimate, deaths due to medical errors exceed the number attributable to the 8th-leading cause of death. More people die in a given year as a result of medical errors than from motor vehicle accidents (43,458), breast cancer (42,297), or AIDS (16,516).

Total national costs (lost income, lost household production, disability and health care costs) of preventable adverse events (medical errors resulting in injury) are estimated to be between $17 billion and $29 billion, of which health care costs represent over one-half.

In terms of lives lost, patient safety is as important an issue as worker safety. Every year, over 6,000 Americans die from workplace injuries. Medication errors alone, occurring either in or out of the hospital, are estimated to account for over 7,000 deaths annually.

Medication-related errors occur frequently in hospitals and although not all result in actual harm, those that do, are costly. One recent study conducted at two prestigious teaching hospitals, found that about two out of every 100 admissions experienced a preventable adverse drug event, resulting in average increased hospital costs of $4,700 per admission or about $2.8 million annually for a 700-bed teaching hospital. If these findings are generalizable, the increased hospital costs alone of preventable adverse drug events affecting inpatients are about $2 billion for the nation as a whole.

These figures offer only a very modest estimate of the magnitude of the problem since hospital patients represent only a small proportion of the total population at risk, and direct hospital costs are only a fraction of total costs. More care and increasingly complex care is provided in ambulatory settings. Outpatient surgical centers, physician offices and clinics serve thousands of patients daily. Home care requires patients and their families to use complicated equipment and perform follow-up care. Retail pharmacies play a major role in filling prescriptions for patients and educating them about their use. Other institutional settings, such as nursing homes, provide a broad array of services to vulnerable populations. Although many of the available studies have focused on the hospital setting, medical errors present a problem in any setting, not just hospitals.

Errors are also costly in terms of opportunity costs. Dollars spent on having to repeat diagnostic tests or counteract adverse drug events are dollars unavailable for other purposes. Purchasers and patients pay for errors when insurance costs and co-payments are inflated by services that would not have been necessary had proper care been provided. It is impossible for the nation to achieve the greatest value possible from the billions of dollars spent on medical care if the care contains errors.

But not all the costs can be directly measured. Errors are also costly in terms of loss of trust in the system by patients and diminished satisfaction by both patients and health professionals. Patients who experience a longer hospital stay or disability as a result of errors pay with physical and psychological discomfort. Health care professionals pay with loss of morale and frustration at not being able to provide the best care possible. Employers and society, in general, pay in terms of lost worker productivity, reduced school attendance by children, and lower levels of population health status.

Yet silence surrounds this issue. For the most part, consumers believe they are protected. Media coverage has been limited to reporting of anecdotal cases. Licensure and accreditation confer, in the eyes of the public, a "Good Housekeeping Seal of Approval." Yet, licensing and accreditation processes have focused only limited attention on the issue, and even these minimal efforts have confronted some resistance from health care organizations and providers. Providers also perceive the medical liability system as a serious impediment to systematic efforts to uncover and learn from errors.

The decentralized and fragmented nature of the health care delivery system (some would say "nonsystem") also contributes to unsafe conditions for patients, and serves as an impediment to efforts to improve safety. Even within hospitals and large medical groups, there are rigidly-defined areas of specialization and influence. For example, when patients see multiple providers in different settings, none of whom have access to complete information, it is easier for something to go wrong than when care is better coordinated. At the same time, the provision of care to patients by a collection of loosely affiliated organizations and providers makes it difficult to implement improved clinical information systems capable of providing timely access to complete patient information. Unsafe care is one of the prices we pay for not having organized systems of care with clear lines of accountability.

Lastly, the context in which health care is purchased further exacerbates these problems. Group purchasers have made few demands for improvements in safety. Most third party payment systems provide little incentive for a health care organization to improve safety, nor do they recognize and reward safety or quality.

The goal of this report is to break this cycle of inaction. The status quo is not acceptable and cannot be tolerated any longer. Despite the cost pressures, liability constraints, resistance to change and other seemingly insurmountable ba