In 1999, the Institute of Medicine conducted a study showing that medical errors contributed to the morbidity rate of hospitalized patients in the U.S. by as many as 44,000 to 98,000 deaths (Woo, Ranji & Salganicoff, 2008). Ranking as 5th to 8th among the major causes of deaths in the country, medical errors surpassed the numbers caused by motor vehicle accidents, breast cancer and AIDS at that time. The IOM study caused a snowballing of further research and policy making with regard to medical error reduction. More than a decade later, preventable medical errors persist. One such case involved the excessive administration of Lepirudin for thrombocytopenia in a Boston hospital which led to patient bleeding and death and a $1.25 million dollar settlement months after (Medication error lawsuit, 2011). Experts agree that in most cases, the problem is not because of the inadequacies of health care professionals per se but in flaws within the medical and hospital systems (Olden & McCaughrin, 2007). As the issue is largely organizational in nature, addressing the problem requires assessing how hospital organizational structure and governance, culture and social responsibility contribute to the problem.
Organizational structure consists of relationships reflecting hierarchy levels and extent of managerial control, the division of employees into work units which form departments, and inter and intra-departmental communication and collaboration systems (Olden & McCaughrin, 2007). Referred to as structural form, behavioral and social relationship patterns emerge within this structure and reflect power, authority, divisions of labor, work flow and collaboration (Olden & McCaughrin, 2007). Structural form contributes to medical errors in several ways. First, ambiguity in the work flow results in varied interpretations, actions and outcomes. In the medication error case mentioned above, it may not have been clear what was needed to be done next if a blood sample for PTT monitoring came back as “compromised” (Medication error lawsuit, 2011). In this situation, nurses can opt to do nothing or have another PTT drawn.
Second, inefficient and limited communication systems result in misinterpretations among health care professionals and inappropriate clinical decisions. In the case involving Lepirudin overdose, miscommunication between the prescriber and the nurse contributed to the error (Medication error lawsuit, 2011). Third, the lack of coordination delays the performance of interventions which are crucial especially in emergent conditions. Fourth, the absence of integration or team work has been shown to positively correlate with medical errors. Fifth, the lack of power among health care professionals to improve patient safety through the development of clinical guidelines among other activities reduces their sense of accountability and motivation to perform well (Olden & McCaughrin, 2007).
On the other hand, organizational governance pertains to methods that organizations use to influence employees to fulfill their role in the attainment of organizational goals (Foss & Klein, 2008). Poor organizational governance impacts medical error rates. In order to steer the organization towards quality improvement initiatives for patient safety, there must be full management support (Slater et al., 2012). Without strong leadership and supervision, solid employee support for QI is not assured and change will likely fail. Further, the absence of education and training deprives employees the opportunity to develop the knowledge, skills and attitudes relevant to attaining the organizational goal of medical error prevention (Olden & McCaughrin, 2007). Knowledge and skills encompass patient safety and medical error prevention, current evidence and the efficient use of supportive technologies. Competencies in multidisciplinary teamwork are also not innate but need to be developed through training programs (Contratti, Ng & Deeb, 2012). The lack of effective reporting systems to monitor medical error incidence further perpetuates the problem (DonHee, Lee & Schniederjans, 2011) while the absence of incentives for excellent performance with regard to patient safety may reduce employee motivation (Olden & McCaughrin, 2007).
A comparative survey of U.S. (sample size = 1,891) and U.K. doctors echoes the organizational structure and governance problems noted above (Roland et al., 2011). The study showed that U.S. doctors were significantly less likely than U.K. doctors to have formulated practice guidelines and participated in formal education and training for reducing medical errors (Roland et al., 2011). Though recertification is deemed highly necessary by U.S. doctors and the process may require continuing education on patient safety, it does not always ensure a link between knowledge and practice as factors with the work environment were found to significantly affect performance (Hawkins et al., 2009). In organizations where providing safe patient care is not a cultural value, behaviors consistent with this value will likely not be expected, encouraged or rewarded.
Organizational culture comprises the values, beliefs and ideals and commonly shared by organization members (Bellot, 2011). In general, an organizational culture that does not uphold patient safety equates to low quality care and the continued occurrence of medical errors because of the tendency of organizations to deny that an incident indeed took place and defend itself against accountability claims (Bell et al., 2012; Medication error lawsuit, 2011). It permits the use of deception by health care professionals to cover up for their mistakes. It further reflects a lack of focus on social responsibility, a corporate virtue which means providing patients with access to quality care that meets their needs. A socially unresponsive organization will not measure its performance against standards, institute quality improvement and greater transparency or adopt best practices.
As of 2011, it is estimated that only about 25% of the 6,000 hospitals in the U.S. have quality improvement programs in place despite research results and recommendations from regulatory agencies (Andel et al., 2012). Medicare has continued with its fee-for-service scheme which permits hospitals to obtain payment for treating conditions caused by medical errors. In a sense, hospitals would increase their bottom line the more treatments patients would have rather than less. Clearly, a system of reimbursement regardless of outcomes of care contributed to the sluggish adoption of QI recommendations. However, recent policy reforms embodied in the Patient Protection and Accountable Care Act now provide strong incentives for organizations meeting set performance standards which include patient safety (Accountable care organizations, 2012). An evolving health system brought about by policy changes requires that hospitals decisively confront medical errors as a clinical issue.
In order to prevent medical errors, capital and human resources need to be allocated in the setting up of an electronic medical records system with electronic prescribing capabilities and a multidisciplinary patient safety committee to spearhead quality improvement initiatives (Lambert, 2010; Andel et al., 2012). Both efforts address ethical issues relating to non-maleficence and beneficence by minimizing the probability of preventable drub overdosing and other medical errors from occurring, events that lead to economic and quality of life losses or deaths (Morrison, 2011). A system for disclosing medical errors to the organization and patients and providing the latter prompt and fair compensation should also be put in place in line with professional accountability, patient advocacy as well as the ethical principles of veracity and justice (Bell et al., 2012). QI initiatives geared to meet national standards will ensure the best possible care for patients and translates to lesser, outcome-dependent costs.
Other organizational changes need to be implemented. In a model on preventing medical errors proposed and tested by DonHee, Lee & Schniederjans (2011), organizations need to have preventive and corrective systems in place. Preventive systems include information technology, EMR, training and education and procedures while corrective systems include error reporting mechanisms, error analysis, further training and education as well as system redesign (DonHee, Lee & Schniederjans, 2011). These systems impact the organizational structure in that managerial roles need to be expanded to include ensuring that employees obtain the necessary education and training to use ICT, the EMR system and to develop awareness and skills on medical error prevention. Employees must also be empowered to initiate the improvement of standard operating procedures through the development of practice guidelines.
Further, there is a greater need to monitor employee performance and to reinforce favorable ones. Error reporting policies should be placed within the context of patient advocacy and errors should not be dealt with punitively or employees will fail to report. Rather, it should be done in the spirit of quality improvement and learning. Risk management teams tasked to collect, investigate and analyze medical error incidents and generate recommendations for the organization need to be established and strengthened. A committee to oversee employee education and training is necessary and there is a need to foster collaboration within and among the different disciplines involved in providing health care as well. Overall, a culture of social responsibility and commitment to quality patient care will ensure that preventive and corrective systems are accepted and redesign, if necessary following evaluation, is welcomed.
In summary, medical errors remain a reality in hospitals since the landmark 1999 Institute of Medicine report. A common type of medical error involves the erroneous administration of medications which may lead to irreversible complications such as hemorrhage with Lepirudin overdose. However, errors most often occur because of organizational factors more than individual health care professional attributes or actions. Problems with the workflow, accountability systems as well as systems of communication, coordination, collaboration need to be addressed and the use of technology can assist the effort. Leadership and greater oversight through reporting systems as well as creating functional committees or teams which will focus on medical error reduction are indispensable. Employee education/training programs will also positively impact the issue. Finally, effective changes from QI will be successful and sustained with organizational culture changes adopting ethical principles and social responsibility.
References
Accountable care organizations: Improving care coordination for people with Medicare (2012, March 12). Retrieved from http://www.healthcare.gov/news/factsheets/2011/03/accountablecare03312011a.html.
Andel, C., Davidow, S.L., Hollander, M., & Moreno, D.A. (2012). The economics of health care quality and medical errors. Journal of Health Care Finance, 39(1), 39-50.
Bell, S.K., Smulowitz, P.B., Woodward, A.C., Mello, M.M., Duva, A.M., Boothman, R.C., & Sands, K (2012). Disclosure, apology, and offer programs: Stakeholders’ views of barriers to and strategies for broad implementation. Milbank Quarterly, 90(4), 682.
Bellot, J. (2011). Defining and assessing organizational culture. Nursing Forum, 46(1), 29- 37.
Contratti, F., Ng, G., & Deeb, J., (2012). Interdisciplinary team training: Five lessons learned. American Journal of Nursing, 112(6), 47-52.
Foss, N.J., & Klein, P.G. (2008). Organizational governance. In Wittek, R., Snijders, J., & Nee, V. (Eds.), The Handbook of Rational Choice Social Research. New York, NY: Russell Sage Foundation.
Hawkins, R., Roemheld-Hamm, B., Ciccone, A., Mee, J., & Tallia, A. (2009). A multimethod study of needs for physician assessment: Implications for education and regulation. Journal of Continuing Education in the Health Professions, 29(4), 220- 234.
Lambert, A. (2010). Health care reform to have impact on ethics. Medical Ethics Advisor, May 2010, 54.
Medical error lawsuit resulting in death of woman settles for $1.25 million (2011). Retrieved from http://www.lubinandmeyer.com/cases/medication-error.html
Morrison, E.E. (2011). Ethics in Health Administration: A Practical Approach for Decision Makers (2nd ed.). Massachusetts, MA: Jones and Bartlett Publishers.
Olden, P., McCaughrin, W. (2007). Designing healthcare organizations to reduce medical errors and enhance patient safety. Hospital Topics, 85(4), 4-9.
Roland, M., Rao, S., Sibbald, B., Hann, M., Harrison, S., Walter, A., & Campbell, E. (2011). Professional values and reported behaviours of doctors in the USA and UK: quantitative survey. BMJ Quality & Safety, 20(6), 515-521.
Slater, B.L., Lawton, R., Armitage, G., Bibby, J., & Wright, J. (2012). Training and action for patient safety: Embedding interprofessional education for patient safety within an improvement methodology. Journal of Continuing Education in the Health Professions, 32(2), 80-89.
Woo, A., Ranji, U., & Salganicoff, A. (2008, May). Reducing medical errors. Retrieved from http://www.kaiseredu.org/Issue-Modules/Reducing-Medical-Errors/Background- Brief.aspx.
