Theory of medical errors (note 1)

Volume 8, Issue 3, June 2024     |     PP. 59-74      |     PDF (161 K)    |     Pub. Date: December 20, 2024
DOI: 10.54647/pmh330369    12 Downloads     521 Views  

Author(s)

Murat M. Makhambetchin, National Scientific Center of Traumatology and Orthopedics named after academician N.D. Batpenov, Astana, 010009, Republic of Kazakhstan
Sergey V. Lokhvitskiy, Karaganda Medical University, Karaganda, 100017, Republic of Kazakhstan
Yermek M.Turgunov, Karaganda Medical University, Karaganda, 100017, Republic of Kazakhstan
Kayrat T. Shakeyev, Karaganda Medical University, Karaganda, 100017, Republic of Kazakhstan

Abstract
The unique individuality of patients' psychophysiology and the human factor of the physician are primary causes of medical errors. Our current understanding of these causes is insufficient to develop reliable control programs. Among the strategies to reduce errors, the most critical is admitting and openly discussing them among peers; however, this approach is complex and challenging to implement.
The goal of this publication is to introduce a new classification of certain aspects of the emerging theory of medical errors, aimed at enhancing the understanding of this issue.
The issue of medical errors is complex and often misunderstood, leading to irrational approaches to solving it—namely, attempting to decrease errors through punishment.
A rational, comprehensive approach should include: quality control of initial education, enhancement of the mentorship system, development and continuous refinement of clinical guidelines, exploration of error issues in medical school and during postgraduate training, training in error analysis itself, and quality control over the analysis of adverse outcomes without attributing blame or administering punishment.
For effective error analysis, categorizing errors by their primary causes is pragmatically valuable. Errors due to subjective reasons constitute the most complex and inadequately studied part of this issue. It's important to note that the mechanism of an error may not align with its cause. This text provides examples of common error mechanisms, highlighting the distinction between causes and mechanisms and underscoring the importance of identifying the mechanism.
Studying the theory of medical errors is equivalent to mastering a distinct scientific discipline. It systematizes known knowledge in new, previously unexplored interrelations.
The theory aims to improve understanding of the problem initially among physicians. Without grasping this issue, expecting a balanced and objective societal stance towards physicians' errors is challenging.

Keywords
theory of medical errors; admitting errors; error analysis; causes of errors; mechanisms of errors.

Cite this paper
Murat M. Makhambetchin, Sergey V. Lokhvitskiy, Yermek M.Turgunov, Kayrat T. Shakeyev, Theory of medical errors (note 1) , SCIREA Journal of Health. Volume 8, Issue 3, June 2024 | PP. 59-74. 10.54647/pmh330369

References

[ 1 ] Farley DO, Battles JB. Evaluation of the AHRQ patient safety initiative: framework and approach. Health Serv Res. 2009 Apr;44(2 Pt 2):628-45. doi: 10.1111/j.1475-6773.2008.00931.x. PMID: 21456107; PMCID: PMC2677032.
[ 2 ] Spiess BD. Human error in medicine: change in cardiac operating rooms through the FOCUS initiative. J Extra Corpor Technol. 2011 Mar;43(1):P33-8. PMID: 21449238; PMCID: PMC4680095.
[ 3 ] Teymourzadeh E, Mehdizadeh P, Yaghoubi M, Firoozjaie IT. Assessment and Reduction of Human Error using SHERPA Technique in Chemotherapy Department of a Large Military Hospital. Iran J Nurs Midwifery Res. 2023 Jul 24;28(4):426-429. doi: 10.4103/ijnmr.ijnmr_382_21. PMID: 37694207; PMCID: PMC10484388.
[ 4 ] Rodziewicz TL, Houseman B, Hipskind JE. Medical Error Reduction and Prevention. 2023 May 2. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan–. PMID: 29763131.
[ 5 ] Clough JD, Macklis RM, Nadzam DM. It's time medicine stopped burying its mistakes. Cleve Clin J Med. 2000 Apr;67(4):299-300. doi: 10.3949/ccjm.67.4.299. PMID: 10780103. Rovner J. Washington wakes up to medical mistakes. Bus Health. 2000 Jan;18(1):19. PMID: 10788134.
[ 6 ] Lemonick MD. Doctors' deadly mistakes. Medical errors kill up to 98,000 Americans yearly; a new report says that number could be cut drastically. Time. 1999 Dec 13;154(24):74-6. PMID: 10724802.
[ 7 ] Crane M. Medical mistakes. Must doctors take the rap? Looking beyond the IOM report. Med Econ. 2000 Nov 20;77(22):108-10, 115-8, 123-4. PMID: 11116441.
[ 8 ] Shuren AW. Health care delivery errors: patient safety falls prey to politics. J Pediatr Health Care. 2001 Jan-Feb;15(1):42-4. doi: 10.1067/mph.2001.112290. PMID: 11174664.
[ 9 ] Altman DE, Clancy C, Blendon RJ. Improving patient safety--five years after the IOM report. N Engl J Med. 2004 Nov 11;351(20):2041-3. doi: 10.1056/NEJMp048243. PMID: 15537902.
[ 10 ] Richardson WC, Berwick DM, Bisgard JC, Bristow LR, Buck CR, Cassel CK, Coye MJ, Detmer DE, Grossman JH, James B, Lawrence DM, Leape L, Levin A, Robinson-Beale R, Scherger JE, Southam AM, Wakefield M, Warden GL, Corrigan JM. The Institute of Medicine Report on Medical Errors: misunderstanding can do harm. Quality of Health Care in America Committee. MedGenMed. 2000 Sep 19;2(3):E42. PMID: 11104488.
[ 11 ] Brennan TA. The Institute of Medicine report on medical errors--could it do harm? Tex Med. 2000 Jun;96(6):13-5. PMID: 10876367.
[ 12 ] Hallam K. Elbows fly in medical-errors game. Mod Healthc. 2000 Feb 21;30(8):32. PMID: 11010039.
[ 13 ] Pretzer M. Legislators begin their effort to curb medical errors. Med Econ. 2000 Jun 19;77(12):31-2, 35, 38. PMID: 11010473.
[ 14 ] Andrus CH, Villasenor EG, Kettelle JB, Roth R, Sweeney AM, Matolo NM. "To Err Is Human": uniformly reporting medical errors and near misses, a naïve, costly, and misdirected goal. J Am Coll Surg. 2003 Jun;196(6):911-8. doi: 10.1016/S1072-7515(03)00236-9. PMID: 12788428.
[ 15 ] Giard RW. Medische fouten: onvermijdelijk, maar bestrijdbaar [Medical errors: inevitable but preventable]. Ned Tijdschr Geneeskd. 2001 Oct 27;145(43):2062-5. Dutch. PMID: 11715589.
[ 16 ] Roman MD, Fleacă SR, Boicean AG, Mohor CI, Morar S, Dura H, Cristian AN, Bratu D, Tanasescu C, Teodoru A, Necula R, Russu O. Failure in Medical Practice: Human Error, System Failure, or Case Severity? Healthcare (Basel). 2022 Dec 9;10(12):2495. doi: 10.3390/healthcare10122495. PMID: 36554018; PMCID: PMC9778633.
[ 17 ] Rocco C, Rodríguez AM, Noya B. Elimination of punitive outcomes and criminalization of medical errors. Curr Opin Anaesthesiol. 2022 Dec 1;35(6):728-732. doi: 10.1097/ACO.0000000000001197. Epub 2022 Oct 3. PMID: 36194145.
[ 18 ] Marx D. Patient Safety and the Just Culture. Obstet Gynecol Clin North Am. 2019 Jun;46(2):239-245. doi: 10.1016/j.ogc.2019.01.003. PMID: 31056126.
[ 19 ] Boulanger J, Keohane C, Yeats A. Role of Patient Safety Organizations in Improving Patient Safety. Obstet Gynecol Clin North Am. 2019 Jun;46(2):257-267. doi: 10.1016/j.ogc.2019.02.001. PMID: 31056128.
[ 20 ] Barsky M, Olson APJ, Astik GJ. Classifying and Disclosing Medical Errors. Med Clin North Am. 2022 Jul;106(4):675-687. doi: 10.1016/j.mcna.2022.02.007. Epub 2022 May 28. PMID: 35725233.
[ 21 ] Higham H, Vincent C. Human Error and Patient Safety. 2020 Dec 15. In: Donaldson L, Ricciardi W, Sheridan S, Tartaglia R, editors. Textbook of Patient Safety and Clinical Risk Management [Internet]. Cham (CH): Springer; 2021. Chapter 3. PMID: 36315764.
[ 22 ] Arnal-Velasco D, Heras-Hernando V. Learning from errors and resilience. Curr Opin Anaesthesiol. 2023 Jun 1;36(3):376-381. doi: 10.1097/ACO.0000000000001257. Epub 2023 Feb 8. PMID: 36794873.
[ 23 ] Gohal G. Models of teaching medical errors. Pak J Med Sci. 2021 Nov-Dec;37(7):2020-2025. doi: 10.12669/pjms.37.7.4506. PMID: 34912437; PMCID: PMC8613064.
[ 24 ] Danino J, Muzaffar J, Metcalfe C, Coulson C. Patient safety in otolaryngology: a descriptive review. Eur Arch Otorhinolaryngol. 2017 Mar;274(3):1317-1326. doi: 10.1007/s00405-016-4291-z. Epub 2016 Sep 13. PMID: 27623822.
[ 25 ] Harolds JA. Quality and Safety in Healthcare, Part LXXXIII: The Culture of Safety in High Reliability Organizations. Clin Nucl Med. 2022 Oct 1;47(10):e673-e675. doi: 10.1097/RLU.0000000000003418. PMID: 33234929.
[ 26 ] Sulistiadi W, Purwadi AG, Asyary A. Addressing the Medical Errors in the Re-Organized Healthcare in Indonesia. Ann Ig. 2020 Sep-Oct;32(5):567-576. doi: 10.7416/ai.2020.2376. PMID: 32744587.
[ 27 ] Makhambetchin M.M. Theory of doctors' mistakes - a special branch of science. Zdravookhranenie Rossiyskoy Federatsii. 2019; 63(4): 214-20. (in Russian)] https://doi.org/10.18821/0044-197X-2019-63-4-214-220