Medical Errors

In 1999 the Institute of Medicine (IOM) released a report entitled To Err Is Human: Building a Safer Health System, which defined medical error as the failure of a planned action to be completed as intended, or the use of a wrong action plan to achieve an aim.

The report, which suggested that as many as 98,000 people die annually from medical errors, generated a significant amount of media and congressional attention and triggered new scholarly research into this issue. If the estimates presented in the report are accurate, medical error is a leading cause of disability and death, responsible for more deaths annually than highway accidents, breast cancer, or AIDS.

Medical errors can occur in hospitals, physicians’ offices, pharmacies, long-term care facilities, ambulatory care centers, and even in care delivered in the home. Examples of medical error include a nurse accidentally administering the wrong dose of a drug, a pharmacist mis-reading a physician' handwritten prescription and providing the patient with the wrong drug with a similar name, a hospital patient not being given a low-salt meal when one is clinically indicated, a diagnostic procedure being performed on the wrong patient, or a surgeon amputating the wrong leg.

Not all medical error results in actual harm to patients. For example, a provider may administer an incorrect medication without causing harm to a patient. However, many errors do result in harm, or adverse event, to the patient. An adverse event takes place when an injury occurs as a result of medical care prolonging hospitalization, producing temporary or permanent disability, or causing death. An error that does not lead to harm is called a “near miss” or “close call” event. One example of a near miss would be medical professionals realizing they are about to deliver the wrong drug to a patient and stopping themselves before actually doing so. Near misses are important to study because they may provide clues on why medical errors commonly occur and how people or health care systems could intervene to prevent error.