DEFINING MEDICAL ERRORS

A medical error has been defined as the failure of a planned action to be completed as intended or the use of a wrong plan or action to achieve an aim. Errors can include problems in practice, products, procedures, and systems.

Errors are further described as adverse events. Important subcategories of adverse events include:

  • Preventable adverse events can be avoided by any means currently available unless the means is not considered standard care.
  • Unpreventable adverse events result from a complication that cannot be prevented.
  • Ameliorable adverse events are not preventable but the severity of injury could have been substantially reduced if different actions or procedures had been performed or followed.
    (AHRQ, 2019a)

In addition to adverse events, other terms used to describe medical errors include near misses, sentinel events, and never events.

Near Misses

A near miss is any event that could have had adverse consequences but did not and was indistinguishable from fully fledged adverse events in all but outcome. In a near miss, an error was committed, but the patient did not experience clinical harm, either through early detection or sheer luck (AHRQ, 2019a).

Sentinel Events

A sentinel event is identified by the Joint Commission Sentinel Event Policy as an event that reaches a patient and results in any of the following:

  • Death
  • Permanent harm
  • Severe temporary harm and intervention required to sustain life
    (TJC, 2021)

Not all sentinel events occur because of an error, and not all medical errors result in sentinel events. Sentinel events can include:

  • Suicide of any patient receiving care, treatment, or services in a staffed, around-the-clock care setting or within 72 hours of discharge, including from the emergency department
  • Unanticipated death of a full-term infant
  • Discharge of an infant to the wrong family
  • Abduction of any patient receiving care, treatment, or services
  • Any elopement of a patient from a staffed, around-the-clock care setting leading to death, permanent harm, or severe temporary harm of the patient
  • Rape, assault, or homicide of any patient receiving care, treatment, or services, or any staff member, licensed independent practitioner, visitor, or vendor while on site
  • Surgery or other invasive procedure performed at the wrong site, on the wrong patient, or that is the wrong (unintended) procedure for the patient
  • Unintended retention of a foreign object in a patient after an invasive procedure, including surgery
  • Severe neonatal hyperbilirubinemia
  • Prolonged fluoroscopy to a single field or any delivery of radiotherapy to the wrong body regions or delivery of the wrong radiotherapy dose
  • Fire, flame, or unanticipated smoke, heat, or flashes occurring during direct patient care caused by equipment operated and used by the hospital (staff do not need to be present)
  • Any intrapartum maternal death
  • Sexual abuse/assault involving a patient and another patient, staff member, or other perpetrator while being treated or on hospital premises
    (TJC, 2021)

Never Events

The National Quality Forum has compiled a set of 29 serious reportable events (SREs), which are consequential, largely preventable. Such events are also called never events—events that should never happen. SREs can be grouped into seven categories, as follows:

  • Surgical SREs (e.g., surgery performed on wrong body parts or the wrong patient, or wrong surgical/invasive procedure performed on a patient)
  • Product/device SREs (e.g., patient death/serious injury associated with use of devices provided by the healthcare setting)
  • Patient-protective SREs (e.g., patient elopement or suicide while in a healthcare setting)
  • Care management SREs (e.g., patient death/serious injury associated with a fall while in a healthcare setting, medication errors)
  • Environmental SREs (e.g., patient death/serious injury associated with the use of restraints while in a healthcare setting, burns, electric shock)
  • Radiological SREs (e.g., patient/staff death/serious injury associated with the introduction of a metallic object into an MRI area)
  • Criminal SREs (e.g., sexual abuse/assault on a patient while in a healthcare setting)

Active and Latent Errors

Active errors (human errors) are those that occur at the point of contact between a human and some aspect of a large system (e.g., a machine). They are generally readily apparent (e.g., pushing an incorrect button or ignoring a warning light) and almost always involve someone at the frontline.

Latent errors are accidents waiting to happen. They refer to a less apparent failure of organization or design that contributes to the occurrence of errors or allows them to cause harm to patients. They are errors in system or process design, faulty installation or maintenance of equipment, or ineffective organizational structure.

When a latent error combines with an active human error, an event occurs (AHRQ, 2019b).