Otolaryngologist Dr. David Roberson has first-hand experience with medical errors. He remembers one near-miss in a patient about to receive a cochlear implant – and says it typifies the kinds of mistakes he and his colleagues have turned up in a national survey.
"I looked at the CT scan carefully to determine if the cochlea would accept the implant," recalls Roberson, from the Department of Otolaryngology and Communication Disorders at Children's Hospital Boston. "I asked a colleague to look at it also, and he commented that the auditory nerves looked small. I then ordered an MRI which showed the patient had no auditory nerves on either side. I came close to performing surgery and putting a major device in a child's head when there was no possibility of benefit, since she had no auditory nerve. I didn't look carefully enough at the entire scan."
Roberson and colleagues sent a brief, anonymous survey to 2,500 members of the American Academy of Otolaryngology-Head and Neck Surgery, and received 466 responses (19 percent). Of these, 210 physicians -- 45 percent -- reported that a medical error had occurred in their practice in the past six months. Errors occurred in all phases of patient care; 78 (37 percent) caused major injury or harm, and 9 (4 percent) were fatal. Both adults and children were affected.
Errors were carefully classified. The largest category, accounting for 19 percent, was technical errors during procedures, and 56 percent of these caused major injury or harm. Next were medication errors (14 percent); these included dosage mistakes and giving medications to which the patient was allergic, or that were contraindicated. Testing errors (10 percent) included physician errors (ordering incorrect tests; not reviewing tests; not acting on the results) and lab errors (lost specimens; errors in labeling and interpretation of results). Surgical planning errors (scheduling mistakes; failing to ensure that all preoperative studies were complete; and judgment errors, such as undertaking surgery when it was risky) accounted for another 10 percent.
Younger physicians were more likely than physicians over age 50 to report errors (approximately 60 versus 40 percent).
Other errors included:
- Equipment errors – equipment not available or improperly assembled; equipment failure (9.4 percent)
- Errors in post-operative care (8.5 percent)
- Wrong site surgery – wrong patient, wrong organ, or wrong side (6 percent);
- Drug errors during surgery (4 percent)
- Communication errors (4 percent)
Roberson and colleagues believe that the proportion of physicians encountering an error -- 45 percent –- is an underestimate. They suggest that doctors may not be trained to recognize errors, and may tend to recall errors that have serious consequences but overlook minor ones.
In one of two editorials accompanying the study, Dr. Lucian Leape of the Harvard School of Public Health concurs, "In the absence of a significant adverse event, most clinicians do not recognize (or admit) errors."
Leape adds that the study provides a unique and useful classification scheme for medical errors. "Not only does this scheme make clinical sense, it would seem to have applicability to other surgical specialties," he writes.
The study is the cover article in the August issue of the journal Laryngoscope. "The probability of an otolaryngologist erring on any individual decision is miniscule," the authors note. "However, because we all make millions of medical decisions, we will all make many errors during our careers… Most errors are made by good or outstanding providers."