by Claudio Bassetti and Richard Hughes
We all remember the professional disappointment that we experienced following a medical error, our own emotional distress, sadness and fear of consequences for the well-being of our patients. Performing an honest and thorough examination of our own errors is an important part of being a „good doctor“. Medical errors can be divided into „diagnostic“ (missed or wrong diagnoses), „treatment“, „preventive“, and others. Negligence is rare, representing only a minority of all medical errors. Because of their exposure to particularly frequent or harmful errors, disciplines such as surgery and intensive care have long had a special interest in this problem. Only recently, following a cultural change towards greater transparency in medicine, has the question of error begun to command the public attention of neurologists.
How often do medical errors occur?
Errors are common and may affect up to one in 10 patients worldwide. leading for example in the US to 50,000 to 100,000 unnecessary deaths each year (1). The frequency of medical errors in neurology is not well known (2). Errors may be observed in up to 5-10% of hospitalized and a similar number of ambulatory patients (1). Misdiagnosis may account for up to half of medical errors in neurological patients (2). Errors in the use of medications (particularly antiepileptics and anticoagulants) are also common (1).
Why do they occur?
Most errors arise from a combination of individual and system failures, but a number of additional factors may contribute.
– Individual failures include personal inexperience, cognitive mistakes (e.g. lapses in memory) and others. Eugen Bleuler, the famous Swiss psychiatrist, described in his book „Autistic and undisciplined thinking in medicine, and how to overcome it“ the „bad cognitive habits“ of doctors in medial practice, including a „magical“ („autistic“) way of thinking, aimed more at the fulfilment of wishes than reflecting reality (3). More recently the cognitive psychology of misdiagnosis was addressed. The use of heuristics (shortcuts), despite their usefulness in every day practice, was found to be a potential source of medical errors (Table from (4): © 2005 American College of Phycicians).
Vickrey et al. used actual neurological cases with a missed diagnosis to illustrate errors arising from the use of five common heuristics (5).
– System failures relate to problems in the organization of health services, including an insufficient staff, incorrect documentation, inadequate communication and poor standardization of processes.
– Other factors also play a role. Medical errors are more common at weekends and at night (6) [see also the January 2014 Presidents‘ Page On weekends] and when medical care takes place under time pressure (in emergencies). Sleepiness and fatigue related to long working hours have also been identified as a contributing factor (7). Further factors probably also play a role. In a surprising recent study, judicial decisions were significantly influenced by the temporal relationship between the decision session and the time of a break (favourable rulings being more common after a break) (8). This is likely to apply to medical decision making as well.
How to disclose medical errors?
Patients wish to be informed about any error, its cause, and possible plans to prevent errors in future. Moreover, patients expect sincere apology and support. However, physicians not infrequently (up to >50% of cases) fail to meet these expectations (1). This can lead to unnecessary litigation. Recommendations on how to approach and disclose errors have been developed and entered medical undergraduate and postgraduate training curricula, at least in some institutions (1).
How to prevent them?
Errors should be reported and investigated at the level of single events and there should be a positive insitutional culture for dealing with the overall problem and the necessary processes should be developed. Reflections and guidelines for healthcare institutions have started to emerge, but their implementation and efficacy have not been proven. Other measures can be taken including the use of techniques to minimize errors related to heuristics and the implementation of recommendations to limit/regulate resident physician work hours (5,7). More research is needed to understand the frequency, causes, and consequences of medical errors in neurology and the best stratetegies to prevent and disclose them.
References:
1. White LR, Gallagher TH. Medical error and disclosure. Handbook of Clinical Neurology 2013;118:107-117.
2. Glick TH. Neurologic patient safety: an in-depth study of malpractice claims. Neurology 2006;65:1284-1286.
3. Bleuler E. Das Autistisch-Undisziplinierte Denken in der Medizin und Seine Überwindung. Berlin: Springer, 1919.
4. Redelmeier DA. The cognitive psychology of missed diagnoses. Ann Intern Med 2005;142:115-120.
5. Vickrey B, Samules MA, Ropper AH. How neurologists think. A cognitive psychology perspective on missed diagnoses. Ann Neurol 2010;67:425-433.
6. Freemantle N, Richardosn M, Wood J, et al. Weekend hospitalization and additional risk of death: an analysis of inpatient data. J R Soc Med 2012;105:74-84.
7. Blum AB, Shea S, Czeisler CA, Landrigan CP, Leape LL. Implementing the 2009 Institute of Medicine recommendations on resident physician work hours, supervision, and safety. Nature and Science of Sleep;3:47-85.
8. Danzinger S, Levav J, Avnaim-Pesso L. Extraneous factors in judicial decisions. PNAS 2011;108:6889-6892.
