SCOPE OF THE MEDICAL ERROR PROBLEM

The World Health Organization reports that 1 in every 10 patients around the world is harmed while receiving hospital care, and 4 out of every 10 patients are harmed in primary and outpatient care, where the bulk of services are offered, often resulting in hospitalization.

In the United States, diagnostic error occurs in about 5% of adults in outpatient care settings, and about half of these errors have the potential to cause severe harm. Extensive autopsy research has shown that diagnostic errors contribute to approximately 10% of patient deaths. Furthermore, medical record reviews demonstrate that diagnostic errors account for 6% to 17% of all harmful events in hospitals (WHO, 2019).

Medication errors are among the most common errors in both outpatient and inpatient settings. Each year in the United States, 7,000 to 9,000 people die due to a medication error. In addition, many other patients experience but often do not report an adverse reaction or other complications related to medication. Medication errors may be due to human errors but often result from a flawed healthcare delivery system with inadequate backup to detect mistakes (Tariq et al., 2021).

High error rates with serious consequences are most likely to occur in intensive care units, operating rooms, and emergency departments. Medical errors are also associated with extremes of age, new procedures, urgency, and the severity of the medical condition being treated (Carver et al., 2020).

Global Burden of Disease study results suggest that mortality associated with adverse effects of medical treatment has decreased modestly over the past 25 years, although the degree of improvement varies by state. Data indicate that:

• Adverse effects of medical treatment are common.
• The vast majority of adverse events that occur in patients who die are not the primary cause of death.
• Only a relatively small fraction of these events is due to medical error.
• Population-adjusted adverse effects of medical treatment rates have been slowly decreasing.
  (Sunshine et al., 2019)

Looking at malpractice payout statistics in all settings provides a broad view of medical errors overall; however, these show only a fraction of the actual number of medical errors, as most patients who are harmed by error do not seek damages, and many who do are denied compensation. An analysis of malpractice payout statistics for 2019 based on the U.S. Department of Health and Human Services’ National Practitioner Data Bank Public Use Data File are reported in the table below.

MALPRACTICE PAYOUTS *

(NPDB, 2020)
By patient type	44% inpatient 39% outpatient 7% unknown 10% both
Related to errors in …	Diagnosis, 34% Surgery, 21% Treatment, 21% Obstetrics, 10% Medication, 5% Monitoring, 3% Anesthesia, 3% Equipment, 1% Behavioral health, 1% IV and blood products, 1%
Severity of outcome	Death, 30% Significant permanent injury, 18% Major permanent injury, 19% Quadriplegic, brain damage, lifelong care, 12% Minor permanent injury, 8% Major temporary injury, 8% Minor temporary injury, 4% Emotional injury only, 1%
* Figures may be rounded.

Progress in Patient Safety

More than two decades have passed since the modern patient safety movement began, and errors remain a serious concern. However, the movement has made significant inroads into understanding why medical errors occur and effective strategies for their prevention.

MILESTONES IN PATIENT SAFETY

Year	Accomplishments
(AHRQ, 2019a; Haskins, 2019)
1999	Institute of Medicine’s To Err Is Human: Building a Safer Health System is published, breaking the silence surrounding medical errors and their consequences. The Healthcare Research and Quality Act of 1999 is signed into law, designating the agency as the federal lead in patient safety.
2000	The first National Summit on Medical Errors and Patient Safety is held to review information needs involved in the process of reducing medical errors and improving patient safety. Doing What Counts for Patient Safety: Federal Actions to Reduce Medical Errors and Their Impact details more than 100 actions federal entities can take to address threats to patient safety.
2001	Evidence Report No. 43: Making Health Care Safer is published, aiming to collect and critically review existing evidence on practices relevant to improving patient safety.
2002	The National Patient Safety Goals program releases its first list of standards, including the creation of an organizational culture of commitment to safety, resulting in a 62% reduction in fall-related injuries.
2003	Patient Safety Indicators are introduced, which include a set of measures that can be used with hospital inpatient discharge data to provide a perspective on patient safety. AHRQ WebM&M, Morbidity & Mortality Rounds begins online, which includes expert analyses of medical errors and interactive learning modules on patient safety.
2004	The Institute for Healthcare Improvement encourages hospitals and providers to take six key steps to reduce patient harm, resulting in 122,000 fewer preventable deaths. AHRQ health information technology portfolio identifies challenges and provides solutions, best practices, and tools for utilization of new information technology by hospitals and clinicians. Implementing Reduced Work Hours to Improve Patient Safety is developed to help address patient safety issues related to extended work hours.
2005	AHRQ Patient Safety Network: Advances in Patient Safety: From Research to Implementation focuses on implementation of change to incorporate new practices.
2006	TeamSTEPPS is introduced, which is an evidence-based teamwork system to improve communication and teamwork skills among healthcare professionals by empowering any team member to speak up to prevent medical errors.
2007	Transforming Hospitals: Designing for Safety and Quality reviews the case for evidence-based hospital design and how it increases patient and staff satisfaction and safety, quality of care, and employee retention. Questions Are the Answer campaign begins, designed to promote better two-way communication between providers and patients. The World Health Organization addresses the goal of reducing surgical errors. Its Safe Surgery Saves Lives global effort focuses on surgical site infections, safe anesthesia, safe surgical teams, and measurement of surgical services.
2008	Project RED’s Patient Safety and Quality: An Evidence-Based Handbook for Nurses is introduced, which is a protocol for Re-Engineered Discharge (RED) to improve patient safety, reduce costs, and boost patient satisfaction. The Association of American Medical Colleges creates the Integrating Quality Initiative to help member medical schools and teaching hospitals achieve safe, high-quality, and high-value care.
2009	AHRQ coordinates the development of common formats for reporting and analysis of patient safety data.
2010	Johns Hopkins University School of Medicine develops a checklist that results in a dramatic drop in the infection rates in their hospital from 11% to zero. The I-PASS Handoff Bundle, created by the I-PASS Study group to teach a standardized approach to handoffs in inpatient settings, is begun and yields a 30% drop between 2010 and 2013 in harmful medical errors that occur with handoffs. The Affordable Care Act of 2010 helps advance patient safety through collaborations such as the Partnership for Patients, which focuses on reducing hospital-acquired conditions such as infections, pressure injuries, and adverse drug events.
2017	AHRQ estimates that hospital-acquired conditions are reduced by 13% from 2014 to 2017.

More than twenty years after the 1999 publication of To Err Is Human, medical errors continue to be a serious concern. While much work has been done to date, much remains to be accomplished. The patient safety movement has had many significant successes, one of which is recognizing that errors in healthcare are typically not related to one person’s error or lack of education, but rather they occur because of a series of miscommunications, loss of information, or other system errors and flaws (Haskins, 2019).