I agree completely  with the above comment.

I have been  practicing since 1969. I can recall 2 errors.

One day I came across a patient who was putting out a lot of urine  without a clear cause.

I eventually realized he was getting low dose  IV dopamine and no one realized it.

No harm was done ( thankfully). The second time was when a nurse told me she was perplexed

that despite our "wonderful" heparin protocol that a patient's PTT remained infinite for 2 days.

After careful review,  we determined that there was a mistake in the heparin concentration

which had been overlooked.No harm was done( thankfully). I may have missed some  errors.

But I am  not convinced that it is  as big a problem  as described in the press. I would like to

be enlightened if I am wrong. 

No other profession would allow themselves to be judged by such flawed metrics.  For the purposes of this evaluation every infection, every drug reaction, every decubitus is classified as a medical error. Shame on the Institute of Medicine.  Let me give you an exampe:  100 patients have a disease that is 100% fatal unless treated with a very toxic but effective chemothapeutic or immunosuppresent medication. With treatment 70 patients "live" disease free or controled for 10 years or more. 30 patients die of reactions to the drug but were given informed consent of the possiblity and chances of dying from the drug therapy prior to treatment. The salvage rate is 70 lives.  The 30 patients that would have died of their disease but died from know and non-preventable drug related toxicity are classied as 30 DRUG CAUSED DEATHS. 

No one can be against preventing true medical errors and reducing compllications. But a real world metric should be devised that does not undermine patient confidence and provide grist for the malpractice lawsuit industry.

Decision making in medcine is determined by very many variables. Reason being many persons participate in mangement at different levels.

There are patient factors, physician factors, laboratory factors, pharmacy etc

In resource limited areas in the third world, it beyond imagination how lives are saved without the hi-tec equipment and inexhaustible resources of the west.

Third party perceptions, Insurance industry perceptions, Media perceptions have all contributed to a distortion of the term error...

 We need clear criteria on this emotive subject- medical errors.

Several previous comments are on the mark; however, as someone who has practiced extensively in hospital settings for 20 years a couple of the comments are particularly shocking.  First is the comment "when I see errors, I scream about them and they rarely happen."  Obviously----and studies have shown this---- error reporting occurs more in non-punitive environments.  Given 2 settings for care, one in which employees feel free to report and discuss errors with supervisors without being punished versus another setting where employees face sanctions when errors occur, two conclusions can be made.  First, the same amount of errors are likely occurring in both settings----the only differrence is they are not being reported out of fear in the second environment.  Secondly,  the first setting where errors are discussed openly and solutions are developed to avoid making similar errors going forward is the far safer place for the patient even though it's error rates are likely higher when reported freely without sanction.   

Secondly, tort reform is wrong on every level as it is currently debated in many states.  The only way to stop malpractice and the continuing slide of medical care into a new dark age is to stop for-profit practices from occuring which focus on quantity and not quality.  When the for-profits  and those who emulate them, say tort reform is necessary to stop skyrocketing healthcare costs, we all know that the only protection patients have is the threat of liability when healthcare providers are demanded to cut quality and do dangerously more with dangerously less.

I am aware of ongoing Medical errors that range in harm from a "near miss" to sentinel events.

There are a few contributing factors that tend to reappear from my experience.

1) short-cuts: their are ways around existing safety checks that save time, but, put patients in harms way. A policy of double-checks is usually in place on those therapies that are high-risk/prone to error. Not a good place to save time.Abbreviations are short-cuts that cause problems as well.

We had a patient on insulin and MD wrote U instead of units on HandP. Sure enough the physician using this information to enter order thought it 60 instead of 6 U (6 units). The order was entered and validated by pharmacy. Luckily, admitting MD caught the error and no dose was given.

2) communication: physicians communicate with physicians, nurses communicate with other nurses. BUT, nurses take care of the physicians patients. Please include them in patient treatment discussion in some fashion. A little extra time spent, goes a long way.

Especially important, when a pharmacist/nurse contacts you for clarification, please be patient and deal with the concern. They would not bother to contact you if they were not truly bothered by the issue.  

3) Common sense

We had a patient who was admitted for psych issue and told us his dose on anti-seizure med that was extremely high. We kept him on that dose, he had ataxia and fell!  His actual dose should have been 1/3 that of what he reported. We should have been more thorough in this case.

 I have been a critical care nurse for over 20 years.  

We used to think that ventilator-associated pneumonias (VAP) were not preventable - it was inevitable.  By instituting certain measures, we have been able to decrease the incidence of VAP to 0 at our small hospital ICU.  While I don't agree that decubiti, UTIs, and VAPs are necessarily errors, I do think that the awareness that something can be done to prevent them has improved patient care.  I believe the point of the IOM report was to increase awareness of issues.  Through research we may find that there are ways to prevent those poor outcomes that we find inevitable at this time (this has been proven over and over throughout the history of medicine).

Instead of feeling insulted, we need to use this as an opportunity to look at what is harming patients and fix the process. That will gain our patients' respect, expecially if we explain it to them. Many times the root cause is a process issue.  None of us wants to harm the patient.  The nurse who is continually interrupted during medication administration makes a mistake.  The physician whose handwriting is difficult to read causes the pharmacist and nurse to make a mistake. Using unapproved abbreviations leads to mistakes.  All these issues are errors of process.  Communication, or lack there of, can lead to errors - nurses who are scared that physicians will yell at them are less likely to call with issues. That puts the patient at harm.

We all want the best of for our patients so let's look at our processes and our behavior and see how it affects patient care.

I have some experience with IT as well as critical care nursing.  I don't know that EMRs will do much to decrease errors.  EMRs, in and of themselves, may help with a patient's home med list and allergies, but otherwise it is more of a data collection tool.  Maybe we will be able to more accurately collect data on "errors'.

Other parts of electronic documentation may help, though. At our hospital, we scan all our patients and their medications before administering the medications.  If used properly, this can really help decrease med errors.  The other thing that I think will help is physician order entry - it certainly takes interpretation of handwriting out of the mix.  As with any system, if people do not use it properly it can lead to new types of errors.  We all have to be vigilant about using the systems as intended.  

I am not sure I understand how your comment relates to my post. I am all in favor of checklists and mandatory training.  In fact, I have read multiple articles and books on checklists and have passed them onto my upper management.  We use some checklists and have to complete mandatory yearly competencies at the hospital where I work.  Unfortunately, checklists are not the only answer - it is the culture in a hospital that has to change. A nurse has to have the ability (backed up by administration) to question a doctor or force them to use a checklist.  There is very much a feeling by doctors that they are not to be questioned, especially by a nurse. Sometimes, doctors feel other doctors should not question them either.  My guess is that things don't change for multiple reasons - doctors feel it challenges their authority (they really don't like to admit when they are wrong), people are naturally resistant to change, and honestly there are so many poor studies out there we tend to be a bit wary of instituting change too quickly. 

As someone who works in Bioethics, has lived in severe chronic pain for 20 years, and will never recover in my truncated lifetime, from either my condition or my medications, I find a number of disturbing errors in your comment alone.  You asked for a fair metric, correct? Try mine- Logic.

First, you imply that since the 30 patients would have died anyway, their death due to (what you state is) lethal medication is somehow less of an error.  I am quite certain most rational and intelligent people would find such a position objectionable, but that aside, it is a logical fallacy; for that to be true, it would also have to be true that a life saved by a flawless surgery that is extinguished months later by an oncoming bus lessens the saving of that life.  Unless you hold this position as well, it is irrational for you to hold the former, Q.E.D.  Sorry.

Your quotations around the word life ("life") shamelessly insinuate that the lives of the other 70 patients are less valuable or important due to their disease, side effects, lack of functionality, etc.  Again, most rational and intelligent people would find this equally objectionable.  The problem here is that you lack any first hand evidence of what life is like for people who suffer from diseases or conditions of which there is no remedy or cure; I am such a person.  At 19 years old I was put through a battery of tests by doctors certainly more knowledgable than you are in order to determine the likely mental state I would have on the other side of a multi-year process, one, which like your example, offered nothing close to recovery, but no other option either.  The problem with such a process is the uselessness of statistics, or any statistical metric to accurately answer their question; would I want to, or act on, ending my life?  Given that I had neither experienced the outcome, nor could until I lived it, made the exercise academic for the most part.  My doctors knew this.  Furthermore, the credibility of statements such as, "I wouldn't want to live if I was x", is cast in grave doubt on a daily basis. The desire to live in staggering circumstances, with no future, is demonstrated every day, and has been noted throughout history.  Only in the most modern times has the optionality of life grown to include things such as marginal brain damage, partial paralysis, and even blindness.  This is all the more remarkable in light of the fact that the valuation of individual life has spiraled upwards in recent decades, contrary to what your position assumes. Not a fallacy on your part, but seriously flawed reasoning and factually inaccurate.

Taken together, your opinions paint a pretty ugly picture of a healer, made all the worse by your lack of education regarding medical ethics.  Your opening remark is as far as most educated people, not to mention medical ethicists, would need to read. Why? 1) THERE ARE NO OTHER PROFESSIONS PARALLEL TO MEDICINE; 2) OF ALL "PROFESSIONS", MEDICINE SHOULD BE HELD TO NOT JUST THE HIGHEST OF STANDARDS, BUT SOMETHING BEYOND THAT.  Why? Because there has never been in human history, such thing as a "good enough" doctor.  Your seemingly likely disagreement with that statement can only mean a few things: 1) you've never been a patient of anything even mildly serious or painful; 2) you believe doctors do not owe patients anything qualitatively different than in any other business transaction, i.e., entitled to a laissez faire profit motive, using the lowest common denominator in supply quality, "service" which for a surgeon means graduating your attention to detail to a payment scale, or for a diagnostician, limiting the depth to which you research to a similar barometer, etc.; 3) (likely your position) you believe as important as medicine is, it must be valued in any functional society and therefore be subject to some sort of compensation commensurate with it's difficulty of attainment, requisite skill, time, etc.  

Well, #3 sounds pretty good, except for the fact that #3 is identical to #2, it is simply wrapped in nicer paper and presented in a more reasonable sounding manner.  Consider what must follow from #3; as a service deserving of compensation, if such compensation were to not to be provided, or even lessened, then #3 would no longer be providing compensation commensurate with y factors.  if compensation were to drop below the threshold required to attain y factors, then the resulting care would not allow for the expense of the requisite skills, the attainment thereof, etc., and the doctor would not be responsible for substandard practices; Although not axiomatic, most ethicists agree a person cannot be held responsible for a result over which they had no control.  Since you cannot control your inability to use reasonable quality supplies because you are not valued and compensated sufficient to do so, how can you be held responsible?  Other than to not practice, you can't, thus the patient is in the same boat as with #2.  You could potentially warn the patient of the failings of the treatment you were going to have to provide, but given your statement re: informed consent, that seems to be a purely contractual issue for you.  Since informed consent is no more than informing a patient of a failing of medicine or technology, there seems to belittle doubt that you would have a serious problem accepting informed consent and reusing cadaver implants or remanufactured medical equipment.  Surely you know of that widespread practice, and you wonder about patient mistrust? Seriously?

Logic aside, you don't, by your statements at least, seem to belong in practice.  If you want a profession, go be a banker.  You are supposed to be up to the task of holding peoples lives in your hands, but I wouldn't let you near me; your lack of insight into (the two examples I made) of your own comments is profoundly disturbing, and deserving of no trust whatsoever, either in valuation of the trust people place in you or your own intellectual ability to see simplistic deduction and inference.  Leave the more substantial work, such as teaching or medicine, to people who actually have a calling for it.  As for undermining patient confidence, your pre-enlightenment bioethical stance and disregard for the value of human existence- especially people existing such as I do, is doing a bang-up job of deepening the divide.  

As an aside I do believe beneficence is a necessary condition for non-maleficence, even if that means withdrawal or refusal of care.  However, due to attitudes such as yours, I do not believe most doctors are qualified to make such decisions.  With the explosive growth in patient advocacy laws (specifically re: children) and clinical ethics committees, It appears likely that you will not have to bother yourself with such matters for too much longer; other professionals, held to even greater metrics than those you complain about, will be doing it for you.

Are you actually arguing that a medication which is prescribed for a patient but not administered is not an error?  Would you say that a doctor calling patients in the middle of the night because he/she somehow missed the two-year old broadly published study findings alerting doctors not to combine two particular medications due to the high (5-10%) chance of permanent liver damage is not an error?  The thing missing in this debate is the law of the excluded middle, which I seem to be writing a lot about these days.  Polarizing all scenarios into black and white is neither functional, nor the point.  One thing which simply has to be understood by all health care practitioners is that there will never be such thing as a perfect record, and certainly not a perfect hospital.  Even if everything is done "correctly", it is very likely, if not assured, that the paradigm of medical science is flawed (T. Kuhn)

Two issues are jumping out of this blog which warrant consideration (my longer comment, below, not being one of them in that I hope it is not representative).  First, the first-hand accounts.  A brief review of innumeracy (parallel to "illiteracy") will show readers that many posts on this site suffer from a Representativeness Heuristic, i.e., the bubble one practices in is wholly insufficient to extrapolate to any informative degree; all these comments that run along the lines of,"in my..." suffer from this flawed reasoning.

 Second, no mention is made of intentionality.  Why wasn't a demented patient who was capable of leaping out of his bed not restrained to any degree?  If he was a frequent bed-hopper, than yes, it is an error, and a valid one.  If he had never so much as twitched, well, that is something else- unless there is evidence to suggest a preponderance of snap bed-hoppers may be ought there.  If such evidence did exist, I would argue it is an error, a failure to primum non nocere by negligence in preparation to care.  That IS an error.

Consider this example: After being under for a 10 1/2 hr. procedure, and after being moved to a room from recovery, a morphine drip was hooked up, bag hung (this was the old days when there were such bags in patient rooms).  I was incoherent, so my family asked about a plug, for a lamp to read by without disturbing me.  They saw plugs, but certainly weren't going to touch a thing themselves.  A nurse rearranged some plugs, among them being breath count and pulse rate meters.  It's battery set off the alarm, which the nurse then turned off; after all, she was there in the room.  Then she reran the sensor plugs through the bedframe, and plugged the machine back in.  Then the shift changed (my #1 guess for postop and medication accidents in hospitals).  My first nurse introduced my family to the second shift, and they both slid my bed back in place.  The second nurse checked the drip line and machine program, and left.  Later in the evening, the morphine line popped out of the grips; the bag was hanging full-bore open, with the line access door closed and locked.  Error?  I don't know; only if you take into account that neither nurse had checked to see if the sensors had been plugged back in.  They hadn't. No capacitance across the plug, no alarm; and very little breathing.  Error?  Whose?  Did the machine have enough safeguards?  Isn't this a likely scenario of human error?

I am only here to write this to you because my mother, brother, and girlfriend took shifts forcing me to breathe.  If I had been awake, I would have known which line was the morphine, from all too much experience.  They new my breathing couldn't safely drop below 4-5 inhalations/min., but the nurses at the nursing station relied on their monitors, which they somehow read as fine.  Error?  My family was sure something was very wrong.  They kept telling the nurse, who spoke almost no English, that I was getting too much Morphine, that my breathing was dangerously depressed.  The nurse pulled on the locked door; it was secure.  She relied on the earlier shift to set it up properly.  The line looked perfect to her, except for the 5" covered by the locked door, and how could anything have happened to that?  It was locked, after all.

Obviously I lived, with no brain damage.  But only because my family did NOT trust the hospital staff, their machines, or anything else beyond their own sense of preventing harm.  Doctors need to get used to not being just trusted either.  Just because you are vigilant doesn't mean you won't err.  The most you can hope for is to err less.  Nor should there be a level of error which you should pat yourselves on the back about.  Even though it's not achievable doesn't mean you should stop trying.  And in the final analysis, you are better served, even protected, by patients and families not accepting you on blind faith.  As for me, I'll take my cue from Reagan- "trust but verify."