Medical Errors and Critical Care Medicine

It has become apparent to people in the know that "serious and widespread quality problems exist throughout American medicine." Nowhere is that problem more acute than in the care of critically ill patients.

Chassin MR, Galvin RW, The urgent need to improve health care quality. Institute of Medicine National Roundtable on Health Care Quality. JAMA, 280:1000, 1998.

The critical role that errors play in health care quality was galvanized into the public psyche in 2000 by the Institute of Medicine in a major and well-publicized monograph- "To Err is Human: Building a Safer Health System". In this monograph, medical errors were estimated to kill up to 98,000 Americans each year and to be due to human error "60-80%" of the time. That is more people in one year than died in the entire Vietnam War. That is more people than die from automobile accidents, AIDS or breast cancer yearly.

But what has been the response to this report?

By contrast, 13 deaths per year caused by Firestone tires nearly bankrupted the company and caused the recall of 6½ million tires; and an airplane crash initiates a full-scale investigation and root cause analysis.

Awareness of medical errors has patients and payers beginning to register concerns. A Kaiser Family Foundation survey demonstrated that 47% of patients were concerned about medical errors when hospitalized; and the Leapfrog Group, a growing consortium of Fortune 500 companies, is now demanding three quality standards, including intensive care unit staffing. Mr. Bruce Bradley, of General Motors has stated that according to the IOM Study, 1.3 General Motor's employees, retirees or dependents die everyday from medical mistakes.

"Every system is perfectly designed to achieve the results it does."
Don Berwick, MD, Institute for Health Care Improvement

Medical errors can be classified in a number of ways but in general there are two types; errors of "omission", in which the appropriate action was not taken (e.g., inadequate surveillance or insufficient treatment), and errors of "commission", in which an inappropriate action was taken due to incorrect planning or execution. It is generally accepted that errors of omission far outnumber errors of commission in critically ill patients and this is predominantly due to inadequate patient surveillance. It is easy to understand the plethora of errors if you look at the current critical care system design which has numerous points of failure and time delay. View Diagram

The problem of medical errors has been recognized for many years. A RAND study in 1990 demonstrated that failure to adhere to objectively defined criteria for management of congestive heart failure led to a 74% increase in mortality, compared to patients who received good-quality care. The 1991 Harvard Medical Practice Study reported on iatrogenic injury (care team-induced) for patients in New York State. This investigation revealed that most iatrogenic injuries were preventable; and if the death rate from these preventable errors were extrapolated to the entire country the result would be 180,000 avoidable deaths per year. Error in Medicine, JAMA, 272:1851,1994.

Errors in hospitalized patients have been shown to increase morbidity, mortality, length of stay (LOS) and costs. Numerous studies have examined the incidence of medical errors and their impact on patients and the health care system:

• The most comprehensive evaluation of human error in the ICU used an engineering model and outside observers and reported an average of 178 activities per patient per day and 1.7 errors per patient per day (1%). For this 6 bed ICU, a severe or potentially life-threatening error occurred on average twice a day:"
  
  Donchin Y, Gopher D, Olin M, Badihi Y, Biesky M, Sprung CL, Pizov R, Cotev S. A look into the nature and causes of human errors in the intensive care unit. Crit Care Med, 23:294,1995.
  
  This hospital's ICU was functioning at a 99% level of proficiency. However, a 1% failure rate is not tolerated in other high-risk industries. Even a ten-fold improvement (99.9% proficiency rating) would equate to 2 unsafe landings at O'Hare airport everyday, 16,000 pieces of lost mail every hour and 32,000 bank checks directed from the wrong bank account every hour. Error in Medicine, JAMA, 272:1851,1994.
  
  
• Another study of errors used trained observers to record what doctors and nurses said about care or discussed in nursing and physician reports. This study found that "18% of patients suffered an error that led to physical disability or death." The "likelihood of experiencing an adverse event increased about 6% for each day of hospital stay and increased further if the patient spent time in an intensive care unit. The effect on length of stay was dramatic at 8.8 days for patients without adverse events and 23.8 days for those with adverse events."
  
  Andrews LB, Stocking C, Krizek T, Gottlieb L, Krizek C, Vargish T, Siegler M. An alternative strategy for studying adverse events in medical care. Lancet, 349:309, 1997.
  
  
• A recent study noted that "16% of patients admitted to the ICU experienced a human error, and these errors added significantly to length of stay, morbidity and costs."
  
  Bracco D, Favre JB, Bissonnette B, Wasserfallen JB, Revelly JP, Ravussin P, Chiolero R. Human errors in a multidisciplinary intensive care unit: a 1-year prospective study. Intensive Care Med, 27:137-45, 2001.
  
  The potential ramifications of solving the problem of errors in the health care system are huge. The Leapfrog Group has estimated that providing dedicated intensivists is one way to improve the current critical care system, saving from 53,000 -175,000 lives per year.
  
  Young MP, Birkmeyer JD. Potential reduction in mortality rates using an intensivist model to manage intensive care units. Effective Clinical Practice, 6:284, 2000.

Most attention in this country has been focused on medication errors. However, if you look at the number of deaths related to medication errors they are dwarfed by the number of deaths from inadequately staffed critical care units.

Critical care is a complex, non-linear system. As such, it requires systematic redundancy, and rapid and effective feedback control. Application of these principles to the critical care model is necessary to reduce medical errors and provide the kind of patient safety that we need.

Csete ME, Doyle JC. Reverse engineering of biological complexity, Science, 295:1664, 2002.

"We cannot ask our doctors and nurses to work any harder. If we want safer, higher-quality care, we will need to have redesigned systems of care".
Institute of Medicine- Crossing the Quality Chasm, 2001.