http://www.bmj.com/cgi/content/full/322/7285/501

BMJ 2001;322:501-502 ( 3 March )

Editorials

Medical errors: a common problem

It is time to get serious about them

Papers p 517 Letters p 548 Reviews pp 562, 563

Medical errors continue to dominate newspaper headlines. There is rarely an informed comment on likelihood or cause, rather a tacit assumption that they should never happenand an implicit conclusion that they are getting more common. What is the truth? Firstly, errors have always happened. Secondly, there has been no clear indication as to how common they are in the United Kingdomthough a pilot study in this week's issue represents a first attempt to quantify the size of the problem (p 517).¹ Alongside this is the difficulty of indicating risk. To a bereaved relative the knowledge that there was a 1 in 1000 risk is no consolationfor them it was 1 in 1. In a country where millions are spent every week on the national lottery the concept of risk is obviously alien. What is clear, however, is both that we need to know more about errors and to do more about them.

How common are errors? Can they be minimised? And how should we tackle risk management? One problem in assessing the frequency of errors is that we are deeply immersed in a blame culture, so it is hard to persuade people to report them. Many errors do not cause harm, but in many ways these are as important as those that do. They indicate a breakdown in the system or a wrong decision. If we are to learn from mistakes then we need to know about as many as possible so that corrective action can be taken. This requires a cultural change and sensitive handling of the individual making the report. A recent report from Chesterfield has shown a 150% increase in error reporting by threats of disciplinary actionapparently effective but perhaps not the best approach.²

Few reliable studies of adverse events exist. Two seminal studies were reported some years ago from the United States ^{3 4} and Australia⁵ showing adverse event rates of 3.7% and 16.6% of admissions respectively, with intermediate rates in Colorado and Utah. ^{6 7} In the Colorado study rates were higher in the elderly.⁸ Problems arise because of definitions; and retrospective analysis can be subjective. What appeared to be clinically reasonable at the time may be second guessed if an adverse event occurs. Nevertheless, a figure of 5-10% is worrying, particularly since a half or more of these events were deemed preventable.⁸ Similar rates were found for interpreting emergency radiographs.⁹

Finally, we now have some British data from London based on retrospective record review. In their study of over 1000 records in two acute hospitals, Vincent et al found that almost 11% of patients experienced an adverse event, over half of which were deemed preventable judged by ordinary standards of care.¹ More worryingly, at least a third of these events led to disability or death. This was a pilot study but there is no reason to believe that the results are unrepresentative. The frightening extrapolation of these data suggests that in England and Wales adverse events lead to an extra 3 million bed days at a minimum cost of £1bn per year. Only a full scale study can substantiate this estimate, and if the NHS is serious about learning about and reducing errors it should fund such a study.

What can be done about these errors? They cannot be ignored. Once errors are recognised their causes must be analysed so that preventive measures can be applied. Some of the mistakes are caused by systems failuresthis has been shown, for example, with drug errors or wrong transfusions. Clear definition of clinical responsibilities is needed. Fatigue may also cause problems, as does the use of inappropriately junior staff. The main causes of adverse events relate to operative errors, drugs, medical procedures, and diagnosis. Each of these is amenable to prevention. Better surgical training is obvious. This has been taken on board by the Royal College of Surgeons, though concerns remain that, because of shorter training and tighter working hours, young surgeons are less experienced than previously. Better training programmes will also help with medical procedures. Fewer operations and procedures during the night may also help. Drug errors remain a problemno one can remember all the possible drug interactions that may occur, and incorrect dosages are also a recurrent problem. A computer linked pharmacology system, such as that described from Birmingham,¹⁰ seems an ideal preventive and learning tool. This system sends warnings when incompatible or otherwise dangerous drugs are prescribed, and the introduction of such a system nationwide could prevent hundreds, indeed thousands, of errors. Errors in diagnosis could be minimised by better training and wider use of protocols and diagnostic algorithms.

Errors are problems that will not go away. A pilot study by the Royal College of Physicians into deaths after admission for medical emergencies suggests that some error occurred in as many as one in five cases, although not necessarily leading to an adverse event (unpublished). These data should be interpreted cautiously but do suggest that actual recorded adverse events are the tip of the iceberg. Analogies are often drawn with airline pilots. These are overinterpreted in that an aeroplane should behave predictably on all occasions, whereas every patient is different and the same disease can present in myriad ways. Nevertheless, we can learn from the airlines, as David Johnson suggests on p 563.¹¹ They spend a much higher proportion of revenue on training and they report all incidents, with "blame" being minimised. This is a habit which we should adopt, but it requires a much more sympathetic approach from management than has pertained in the past.

Even more important, we need, as suggested by Vincent et al¹ and England's chief medical officer¹² to put in place a national system for recording adverse events. This is an enormous undertaking and could be introduced initially in high risk areasbut in the end it should be a matter of course in every medical setting, public and private, in the United Kingdom. Only then will we really learn and improve our practice to the ultimate benefit of the public.

K G M M Alberti, president,. 

Royal College of Physicians of London, London NW1 4LE

© BMJ 2001

This article has been cited by other articles:

• Gough, M H, Buss, P., Wilson, T., Turton, C., Nottingham, J., Rubin, G., Horton, R., Maran, N. J, Glavin, R. J, Grunewald, R. A, Mack, C. J, Root, T., Stefanou, A., Siderov, J., de Lemos, M., Langford, N J, Martin, U, Kendall, M J, Ferner, R E, Smith, N., Burns-Cox, N., Solomon, L., Holmes, S. (2001). Medical errors. BMJ 322: 1421-1421 [Full text]  

Rapid Response responses to this article:

Read all Rapid Response responses

Electronic patient records - the begining of recording & preventing error

Dr Robert Varnam, GP & Clinical Research Fellow , School of Primary Care, University of Manchester

bmj.com, 2 Mar 2001 [Response]

The uses of error

richard horton, editor, the lancet

bmj.com, 2 Mar 2001 [Response]

Practical Immediate Action for Adverse Events

Assoc. Peof. Leslie Reti, Chair, Adverse Event Review Panel , Royal Women's Hospital, Melbourne

bmj.com, 2 Mar 2001 [Response]

common problem but the main reason?

Dr Vasantha Kumar, Consultant Physician/ Clinical Director (Medicine) , Milton Keynes Hospital

bmj.com, 3 Mar 2001 [Response]

Packaging of drugs-a disaster waiting to happen

David Shlugman, Consultant Anaesthetist , Radcliffe Infirmary, Oxford

bmj.com, 4 Mar 2001 [Response]

Iatrogenics in France

Renato Barrios, medical resident

bmj.com, 4 Mar 2001 [Response]

Giving injections safely - read the label out loud

Dr Mary B Taylor, G P Principal , Aboyne, Aberdeenshire

bmj.com, 4 Mar 2001 [Response]

The ethos is important

Paul Buss, Consultant Paediatrician , Royal Gwent Hospital

bmj.com, 5 Mar 2001 [Response]

"Knowing is not enough; we must apply. Willing is not enough; we must do."

Dr Tim Wilson, 2000/1 Harkness fellow , Mill Stream Surgery, Benson

bmj.com, 5 Mar 2001 [Response]

The Necessity of Error

William P. Gruzenski MD, Chief of Clinical Services , Clarks Summit State Hospital, PA, USA

bmj.com, 5 Mar 2001 [Response]

Iatrogeny

J. Calinas-Correia, medical practitioner , Cornwall

bmj.com, 6 Mar 2001 [Response]

Terminology of error is important

Greg Rubin, Professor of Primary Care , University of Sunderland

bmj.com, 7 Mar 2001 [Response]

Re: Iatrogeny

ian nesbitt, spr anaesthesia , newcastle

bmj.com, 7 Mar 2001 [Response]

think again! read for your wellbeing!.

gurdeep singh pannu., medical officer. , queen elizabeth hospital,kota kinabalu,sabah,malaysia.

bmj.com, 8 Mar 2001 [Response]

Medical errors- how do we reduce them

Mr U I Esen, Consultant Obstetrician & Gynaecologist , South Tyneside Healthcare Trust

bmj.com, 9 Mar 2001 [Response]

Crisis Avoidance and Resource Management Courses for Doctors

Nicola J Maran FRCA & Ronnie J Glavin MPhil, FRCA, Educational Co-directors, Scottish Clincial Simulation Centre , Scottish Clinical Simulation Centre, Stirling Royal Infirmary, Stirling FK8 2AU

bmj.com, 9 Mar 2001 [Response]

Taking the 'medical' out of 'medical' errors

Stavros Prineas, consultant anaesthetist , Dubbo Base Hospital NSW Australia

bmj.com, 10 Mar 2001 [Response]

Medical errors - the primary care perspective

W F Cunningham, GP & Clinical governance Lead West Northumberland PCG , The Tower, Hexham, Northumberland

bmj.com, 7 Apr 2001 [Response]

Medical Errors - a response

Dr Bill Ryder, Consultant Anaesthetist , Queen Elizabeth Hospital, Gateshead

bmj.com, 9 Apr 2001 [Response]

Related letters in BMJ:

Not again!

Philip J Bickford Smith, J R C Seale, Saad M B Rassam, Tim Wilson, Anmol Malhotra, Mathew Matson, Otto Chan, and Roger M Goss
BMJ 2001 322: 548. [Letter]

Medical errors

M H Gough, Paul Buss, Tim Wilson, Charles Turton, John Nottingham, Greg Rubin, Richard Horton, Nicola J Maran, Ronnie J Glavin, Richard A Grünewald, Carina J Mack, Tim Root, Angela Stefanou, Jim Siderov, Mario de Lemos, N J Langford, U Martin, M J Kendall, R E Ferner, Natalie Smith, Nick Burns-Cox, Lemke Solomon, and Simon Holmes
BMJ 2001 322: 1421. [Letter]

Other related articles in BMJ:

EDITOR'S CHOICE
Medical error: creeping from words to action.

BMJ 2001 322: 0. [Full text]  

EDITOR'S CHOICE [GP]
Medical error: creeping from words to action.

BMJ 2001 322: 0. [Full text]  

PAPERS
Adverse events in British hospitals: preliminary retrospective record review.

Charles Vincent, Graham Neale, and Maria Woloshynowych
BMJ 2001 322: 517-519. [Abstract] [Full text] [extra: Criteria and tables]  

PRESS
Press: Blunders will never cease • How the media report medical errors • A risky business.

Trevor Jackson and Alison Harper
BMJ 2001 322: 562. [Full text]  

PERSONAL VIEWS
How the Atlantic barons learnt teamwork.

David Johnson
BMJ 2001 322: 563. [Full text]  

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