APHM 2017: Unreported medical errors continue to be an “invisible crisis”
Medical errors that go unreported by hospital employees and that are not made public continue to be an “invisible crisis” for the healthcare sector, said Tami Minnier, Vice Chair of Board Joint Commission International at the APHM 2017 conference and exhibition held in Kuala Lumpur, Malaysia from July 25 to 27.
According to a 1999 study by the US Institute of Medicine titled “To Err is Human: Building a Safer Health System”, there are 44,000 to 98,000 deaths per year in the US as a result of preventable medical error.
A nurse with 36 years of experience under her belt, Minnier addressed the leadership void in healthcare, as it is easier for everyone in the healthcare industry to stay the same way it is. She says medical errors occur when everyone is in charge.
A study by the Agency for Healthcare Research and Quality (AHRQ) in 2014, the last published data in the US, showed that 56% of hospital employees did not report any medical errors over a twelve-month period.
Meanwhile, the last definitive study on the number of deaths in the US caused by medical errors reported 400,000 deaths in the year 2013, making medical errors the third leading cause of death in America.
Medical errors continue to be a crisis because the errors are not made public. However, when the mistakes are public, they are very sensationalized, she states.
In order to avoid mistakes, she emphasizes the importance of standardized work and of checklists, especially when it comes to filling out paperwork before a surgery is conducted. She compared going into surgery without checking everything off the list with flying on an airplane without the proper checks being made.
“Why should you allow that in your operating theatres, where people can die at any instance they spot a mistake, without checking if everything is alright?”
When it comes to standardized work, Minnier says it will be better if healthcare providers can all work together. But healthcare providers approach their work in the inverse as they have been trained to work as individuals. Eighty% of what healthcare providers need to do is the same. However “only 20% of what we do is the same, and 80% is different,” she says.
Medical staff also tend to be afraid to address that a mistake was made by someone above them. “It’s really hard to tell your boss that they are wrong, it is very hard. It is even harder, as the boss, to listen,” Minnier states.
When looking at patient safety, healthcare providers need to begin with the acknowledgement that they can also make mistakes, and then learning to listen and work together with their colleagues to prevent errors. The best of the best still make mistakes, she adds.
