Under-Reporting Errors

Medical error is the third leading cause of death in the US, right behind heart disease and cancer. More than 200,000 people die annually as a result of diagnostic mistakes and negligence by healthcare professionals (Washingtonpost, 2016). In the healthcare industry, even the smallest mistakes and oversight could lead to severe consequences for both the patient and professionals. A healthcare professional would be held liable for any discrepancies that causes harm. The following case will analyze the ethical issue and negligence that lead to the death of an elderly woman.

Blendon, R. DesRoches, C. Brodie, M., Benson, J. Rosen, A., & Schneider, A. (2002). Views of practicing physicians and the public on medical errors. New England Journal of Medicine. 347, 1933-1940.

4.3 states that nurses are accountable for their actions and can accept or decline specific tasks based on their knowledge for the sake of professional practice (American Nurses Association, 2015). The nurse being told to do the blood draws incorrectly has the option to step back and review the policy. If he or she does not feel comfortable, the nurse then has the option to decline performing it incorrectly. The nurse has to look out for the patient as well as themselves while taking responsibility for what they chose to do or not do.

PHMC have just one ethical option, and that is to notify the patients about the medical error. The approach they use to handle the communication with the patients is the key.

Healthcare workers are not the only ones fearful of exposing medical errors. The medical institutes themselves operate behind a wall of silence. The IOM first recommended a national medical error reporting system in 1999 and despite attempts by then President Clinton, the American Medical Association and the American Hospital Association successfully lobbied against it (Dyess, 2009). As of 2009, only 20 states have a mandatory medical error reporting system and only a fraction of estimated

Bedside reporting by nurses is currently estimated at 30 per cent and the scope is that of increasing it to a maximum 100 per cent. Currently, the primary resistance to this process of bedside reporting improvement is posed by the nurses, which believe that the process is a waste of time, as well as an indiscretion.

Reducing the incidence of medical error by improving the accuracy and clarity of medical records.

In healthcare systems, there is a concept of fair and just culture. That concept is important to manage the risk. In any organization, errors can happen. But, the best first tool to understand the error is to report it when it happens. Reporting error in healthcare contributes to minimize the risk of recurring.

I agree with you that under reporting medical errors compromise patient safety.  It is important to report mistakes not only to appropriately follow up with the affected patient but also the improve  the protocol if its needed.  I also think that fear plays a huge part on nurses not reporting errors. I think that they are afraid of the consequences or penalties for the errors. I enjoy reading your post.

Instead we can focus on the reason why the person makes the error, and how to reduce the risk of that error to be happening again. Not only that, knowing that making error is humanist can create an environment where individuals are confident that they can report errors or close calls (“near-misses”) without fear of retribution CITATION. For example, if the hospital which the nurse who did a med error is having a culture of safety, the nurse would have no reason to fear of fault, shame, and discipline about the error. She instead should be comfortable to report the error right away to be taken care of, and let the hospital team analyzes the error and find out how to mitigate or prevent future

As previously mentioned the institute of Medicine report dated 1999, every year 44,000 to 98,000 patients die from medical errors. Almost 7,000 of them were medication errors that could have been prevented (ORH, 2004). In addition medical errors are costing our healthcare system an estimated $735 billion to $980 billion (Pubmed, 2012). Medical errors are not a new issue and have been around for a long time. The questions come to mind are how does the problem of medical errors affect our healthcare delivery system? Also how can these medical errors be prevented and reduced?

In this essay “When Doctors Make Mistakes” Atul Gawande (1999) talks about the day when he made a mistake as a doctor. He writes everything that he did step by step to show what he did wrong. He talks about how tried to open her airway and couldn’t so he had attending come help him. He also talks about the patient barely surviving and how the attending had to tell the family that the patient was alive but in a critical condition. He then goes on and talks about other mistakes physicians have made but admits that “all doctors make terrible mistakes” (p.385).

In today's modern world with plenty of technology, it is hard to believe that we cannot figure out how to reduce Medical errors. The issue of medical error is not new in health care organizations. It has been in spot light since 1990's, when government did research on sudden increase in number of death in the hospitals. According to Lester, H., & Tritter, J. (2001), "Medical error is an actual or potential serious lapse in the standard of care provided to a patient, or harm caused to a patient through the performance of a health service or health care professional." Medical errors

According to Reason’s interpretation for the concept of error (1990), it is “the failure of a planned action to be completed as intended – without the intervention of some unforeseeable event; or the use of a wrong plan to achieve an aim.” This definition was somehow subjected to varied reactions, while some accepted this possibility of the error while others thought it was only a pretext for the mistakes done in a medical scenario. Though in the contemporary context this Human Error Theory has gained popularity because the same has been highly in relevance to the Norman’s idea of error, and thus these perspectives which have been built are the ‘Human Factors’ (Carayon, 2008)

On the other hand, it is the right of the patient to know the real problem, and get the medical care that he/she deserves. Especially in case of radiologic procedures, the patient has no way of determining whether the procedures have been performed properly or not. The consequence of the misdiagnosis by a doctor can even be life-threatening for the patient, if the appropriate medical care is not provided at the correct time. Expected Ethical