Indirect liability, presence of a witness, and negative consequences for the patient are the most favorable conditions for an error-friendly environment. These are the conclusions of a study carried out in Germany and published in BMJ. This same journal had already revealed in 2016 that medical error is the third cause of death in the US.

Madrid, April 16, 2018.  Doctors can work for the safety of the patient and follow up on their errors to prevent future harm, but they are also liable for inducing errors and must overcome their consequences, sometimes becoming "second victims". The figures speak for themselves: in 2016, researchers at Johns Hopkins University in Baltimore ranked medical error as the third leading cause of death in the United States. The importance of developing skills to confront this latent duality is vital. And this is where the presentation of hypotheses and clinical discussion enter the foray.

Isabel Kiesewetter, Karen D. Könings, Moritz Kager, and Jan Kiesewtter concluded, in a qualitative study conducted among 159 medical residents and recently published in the British Medical Journal, that "the emotional response dominates the scenario when the student causes the error on his own, whereas, when a colleague is involved, residents tend to report the error and carry out preventive measures." To carry out their analysis, the experts created six scenarios of a case vignette on a hypothetical but realistic situation related to a medical error. The model had already been tested at the Medical Center of the University of Maastrich in the Netherlands and reproduced in Germany.

Asked about their behavioral intentions, when the students caused the error, the participants mentioned communication with colleagues (13% vs. 78%) and carried out preventive measures less frequently (9% vs. 16%) than if another person had caused the error. Along that same line, the students were more empathetic with the patient and prone to inform them about an error when someone had witnessed what happened (40% vs. 21%). In cases of medical harm, students tend to excuse themselves with their patients and face their superiors (35% vs. 22%), whereas if the error does not produce negative consequences, they mostly choose to keep quiet and try to assimilate the lesson (19% vs. 5%).

Although there are no official statistics on deaths due to medical errors, a recent review of the literature in this regard estimates that between 210,000 and 400,000 hospitalized patients die each year due to this cause. By examining studies going back to 1999 and extrapolating the data to all hospitalizations recorded in the United States in 2013, Martin Makary and Michael Daniel, of the John Hopkins University School of Medicine, calculate an average of 251,454 deaths per year. "People die from errors in diagnosis, drug overdose, fragmented care, communication problems, or avoidable complications", the experts say.

Comparing the calculations of Makary and Daniel with data from the Centers for Disease Control and Prevention, iatrogenic damage would cause 9.6% of the deaths in the United States. Only heart diseases and cancer would exceed this number. However, the percentage could be higher, since it only records deaths that occurred in the hospital. Similarly, the scenario of death due to medical error is not included in the reports. This is because the human error that leads to the death of a patient is not a recognized variable in the United States, nor is it in the United Kingdom or Canada. The ICD-10 coding system, the first indicator of health status according to the World Health Organization, limits the inference of most types of medical error. That is, the international classification of diseases does not have a denomination for medical error.

Inherent in performance

While both Makary and Daniel emphasize that human error is inevitable, "the problem,” they say, “should not be exempt from the scientific method." The approach is to evaluate human error as best as possible to design safety systems that reduce its frequency, visibility, and consequences. To date, discussions about its prevention occurred in limited and confidential forums such as hospital committees and internal conferences in which only a part of the adverse effects detected is reviewed and often the lessons learned are not transmitted beyond the service or the institution. Both authors argue that health care work would improve if the data were shared in the same way that doctors share their research on any disease.

Specifically, instead of simply stating a cause of death, the researchers propose to add a box in the death certificates to indicate whether the person died from an avoidable complication associated with medical care. Another strategy would be to implement protocols in the hospitals themselves in order to assess the potential for error in the outcome of death. In short, "the standardization of data collection and measuring the consequences of medical care are a fundamental requirement to create a culture of learning from our mistakes."

Ultimately, for Kiesewetter et al.: "Students must understand that dealing with errors is part of the profession. And educators must understand that it is necessary to educate students so that they know exactly what to do when faced with an error and how to deal with their emotions." It all leads to the need to provide the profession with specific infrastructure and skills.

References 

Kiesewetter I, Könings KD, Kager M, Kiseweter J. Undergraduate medical students’ behavioural intentions towards medical errors and how to handle them: a qualitative vignette study. BMJ Open. 2018;8:e019500. doi: 10.1136/bmjopen-2017-019500

Makary M A, Daniel M. Medical error—the third leading cause of death in the US. BMJ. 2016; 353 :i2139. doi: https://doi.org/10.1136/bmj.i2139