Medical errors are the third leading cause of death in the United States after heart disease and cancer, according to a new estimates published in The BMJ. BMJ estimates suggest medical errors are responsible for 210,000 to 400,000 deaths per year, although accurate data is lacking.
A 2015 U.S. News & World Report found that most common preventable medical errors are:
• Medication errors
• Too many blood transfusions
• Too much oxygen for premature babies
• Healthcare-associated infections
• Infections from central lines
Hospitals were the main site for sentinel events from 2004 to 2015, with 6,248 events reported, according to The Joint Commission. The Joint Commission defines a sentinel event as "an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof." Ambulatory care organizations were the site of 351 sentinel events in that decade.
It is impossible to eliminate human error; after all to err is human. However, ASC administrators can control their response when a medical error occurs in their facility.
"Honesty and transparency [when a medical error has occurred] is important for patient satisfaction and helps reduce the likelihood of the patient taking legal action against the ASC," says Julie Jung RN, MSN, a senior consultant at Avanza Healthcare Strategies. "Never hide the error and place blame."
Here are 10 initial steps for dealing with a medical error at a surgery center, according to Ms. Jung:
1. Provide appropriate treatment and assistance to the patient.
2. After discussion with the ASC's legal representation, properly disclose the error to the patient and the family. Ensure that the provider, administrator and risk manager are present for this discussion.
3. Create an apology and disclosure policy for your ASC and follow it.
4. Initiate an investigation to determine why and how the error occurred.
5. Include physician providers and the medical director in the investigation.
6. Conduct a root cause analysis to determine the cause or causes of the medical error and develop a process improvement plan.
7. Follow-up with family on findings to help provide context for why the error occurred.
8. Report to appropriate agencies — state regulators, CMS, The Joint Commission and the Accreditation Association for Ambulatory Health Care.
9. Bring in a third party for critical incident debriefing.
10. Engage the assistance of an appropriate resource to respond to media requests as well as any comments on social media and websites.
Another important aspect of dealing with a medical error is bolstering staff confidence in the aftermath. First, provide appropriate education related to the specific error and then develop and implement process improvements to reduce the likelihood of a similar adverse event occurring, says Ms. Jung. Involve staff in the development of process changes and improvements.
"Provide second victim resources to staff. Second victims are staff who sustain psychological harm after their involvement in errors that harm patients," she says.
Follow up with your staff at three, six and nine months after completing the root cause analysis and the implementation of the process improvements.
"Time is of the essence for starting an investigation," says Ms. Jung. "Make sure to close the loop with staff and providers on investigation findings and action plans."
In June 2015, the National Patient Safety Foundation released guidelines developed to help healthcare organizations improve the way they investigate medical errors and adverse events. The guidelines include:
• Beginning the root cause analysis process within 72 hours of detection of a medical error
• Creating root cause analysis teams comprised of four to six people
• Reviewing the root cause analysis process at least once a year for effectiveness
