The trauma of medical errors

Twenty years ago, the report “To Err is Human” was published by the Institute of Medicine (today called The National Academy of Sciences) and presented a call to action for national initiatives to create a safer health care delivery system.¹ At that time, the authors reported that 98,000 people die in any given year from medical errors that occur in hospital settings. The article by Drs. Selbst and Krill, Medical errors in the pediatric emergency department: Don’t make these mistakes, quickly reminds us of the devasting effects of medical errors. The authors present and analyze the outcomes of several pediatric/adolescent case studies that clearly highlight medical errors in the emergency departments. The outcomes of these cases revealed that 2 children died and 6 children suffered serious complications: all, most likely preventable. I highly recommend reading this article, examining the cases, and prior to reading the authors teaching points, critically analyze how you, as a pediatric nurse practitioner (PNP), would assess and treat each of the patients in these cases

Your personal analysis of these cases may further inspire you to be active participants in quality improvement (QI) initiatives in your place of employment.

Measures to assure a safer health care delivery system

Prior to the 2000 IOM report, the Institute for Healthcare Improvement was established in 1991 with the overall goal of “redesigning health care into a system without errors”.² Today, nurse practitioners lead QI initiatives in hospitals and outpatient settings to improve health care outcomes; to recognize medical errors; and design programs, policies, or guidelines to prevent future errors. Quality improvement initiatives hold significant promise to continually improve health care outcomes and prevent medical errors.

The nurse practitioner malpractice data bank for the years 1990 to 2014 revealed that malpractice claims involving all NPs, were for diagnostic errors (41.6%) and treatment errors (30.79%).³ It would be interesting to analyze whether rigorous QI initiatives and resultant practice and behavioral changes in specific hospital or outpatient settings over the past 6 years, have reduced the percent of diagnostic and treatment errors made by NPs.

Faculty initiatives to reduce medical errors

As a Director of the Pediatrics NP program, one major outcome goal for PNP student education is prevention of medical errors, with a focus specifically on preventing diagnostic and treatment errors. Clearly, a diagnostic error most likely leads to a treatment error: incorrect diagnosis = incorrect treatment. As the authors, Drs. Selbst and Krill pointed out, ‘premature closure’ is a major problem that leads to medical errors. Diagnostic reasoning is a new skill set for NP students in every discipline. Prevention of premature closure should be a goal for every case study used within NP curriculum and for every case analyzed in clinical practice with their preceptors.

In Case 1, Drs. Selbst and Krill stated that the cardiologist phone consult recommended sending the adolescent home. The provider followed the recommendation, and 8 hours later the adolescent collapsed and died. There is an important lesson here for all health care providers to learn from this case. If you disagree with a diagnosis or recommendation, take additional actions to assure patient safety. The 15-year-old teenager in this case is not unlike many adolescents who present to primary care practices with similar complaints of chest pain, often diagnosed as musculoskeletal pain or costochondritis, and the adolescent is discharged. However, instilling the students with the importance of preventing premature closure is critical to prevention of the more subtle diagnostic errors which were present in Case 1. There was rather clear evidence, at the point of presentation in Case 1, that a further work-up was needed at the time of presentation.

A major goal of NP education is to enable NP students to step out of their role as a Registered Nurse into their new role of a PNP. In their educational programs, PNP students are asked not only to review the recommendations of consultants and other health care providers but to also advocate for a different recommendation if the PNPs analysis of the case differs from the consultants. This skill can be achieved through interprofessional role-playing scenarios to enable all NPs to be confident in their diagnosis and treatment plans based on the presenting case evidence.

Let’s continue to be vigilant in our practices to prevent medical errors, thus attaining what we all strive for: helping our pediatric/adolescent patients return to their normal thriving state of health and well-being.

References

1. Kohn L, Corrigan J, Donaldson M, Institute of Medicine. To Err Is Human. Washington, DC: National Academy Press; 2000.

2. Institute for Healthcare Improvement. History. Ihi.org. Accessed December 14, 2020. http://www.ihi.org/about/pages/history.aspx.

3. Sweeney C, LeMahieu A, Fryer G. Nurse practitioner malpractice data: Informing nursing education. Journal of Professional Nursing. 2020;33(4):271-275. doi:10.1016/j.profnurs.2017.01.002