Medical mistakes are often the result of human error and the stakes are quite high.  A recent IOM report states that in hospitals as many as 44,000 to 98,000 people die each year as the result of medical error.  Even using the lower number this would make medical error the eighth leading cause of death ahead of motor vehicle accidents, breast cancer, and AIDS.  Traditionally, these mistakes are blamed on carelessness, poor training, or even on physician impairment.  From a systems point of view however, the real causes of human mistakes are generally error-likely situations — situations in which a physician or other HCP has unintentionally been “set up” to make a mistake. These error-likely situations are created in the way we design, operate, and maintain our systems; manage our organizations; write our procedures; and conduct our training.  In MCS 1 we focus on the impact or mistakes on the individual physician as a professional person. In this unit we focus on what these errors have in common and on how a systems approach to medicine can result in fewer medical errors and on greater satisfaction for both physician and patient.

At completion of this unit you should be able to:

1. Describe the epidemiology of medical errors - frequency, etiology, mortality and preventability.
2. Demonstrate an ability to analyze the root causes and contributing factors in cases of medical error.
3. Discuss ways to prevent medical error including models of system analysis.

Preparation

1. Be sure to read the Madsen article before class.
2. Read the assigned articles for the week.
3. Take a look at the AHCPR web site on medical error and patient safety and examines some of the articles that intrigue you.
4. Suggestions for the written assignment:
• For a review article you might use one of the readings or even the video shown in lecture this week.
• A possible topic for a position paper: Historically physicians have been reluctant to adopt a systems approach to error. How would you account for their resistance?
• A letter to the editor written in response to a tragedy that is the result of medical error (these will unfortunately not be that hard to find!)

1. In Lecture: Dr. Graber
2. Video Case: First Do No Harm
3. In section:  Continue to analyze the video in light of the lecture and readings for the week.  How many kinds of error can you identify and what are the root causes, contributing factors, and preventability.
4. List ways that physicians can foster a safer health care environment.

1. From the articles on the resources page and your own research, on what order of magnitude do medical errors exist.
2. According to AHCPR data, what are the four primary categories of medical errors?
3. What factors in physician education and culture are influential in attitudes toward error on the part of physicians.