EDUCATION :: COST OF ERRORS
More than cost: The true impact of errors T
By Andy Quintenz
he cost of errors and its antithesis, the cost of quality, is often written about in terms of financial impact to medical laboratories and the healthcare system. This article will highlight the human impact of errors, ways in which the errors can occur within the auspices of the laboratory, and the need for more transparency in discussing the challenge in order to reduce the impact. Medical errors rarely make the head- lines and when they do, it’s typically coverage of the most catastrophic events. The public tends to think of these as being attributable to errors by overworked and hurried doctors, such as surgery per- formed on the wrong side of the body, or a cancer missed on a scan, or simply misinterpreting a patient’s symptoms. In 2000, the Quality of Healthcare in America project through the Institute of Medicine published a landmark report titled To Err is Human: Building A Safer Health System in which the extent of medical errors was detailed along with recommendations for improvement. The report reviewed several studies and esti- mated that between 44,000 to 98,000 deaths occur in the United States each year due to medical errors, leading to national costs between $17 and $29 billion annually. In 2016, the BMJ published a paper detailing a
18 MAY 2022
MLO-ONLINE.COM
new analysis indicating that medical errors were the third leading cause of death in the United States. It further estimated the number of US deaths annually due to medical error at 250,000 minimum, and as high at 400,000. This range equates to 500–1000 deaths every day. This data clearly pointed to a national crisis and despite the time between the 2000 and 2016 reports and now, there has been no indication that the trend has been reversed. While the Institute of Medicine categorizes medical errors into four groups: Diagnostic Errors, Treatment Errors, Preventative Errors, and Communication / Equipment or Other Errors, this profession’s natural focus is in Diagnostic Errors.
Diagnostic errors
Consider a few real-life stories. • A couple that had been married for 50 years were healthy except he re- quired blood thinner medication for a treatable heart condition. However, incorrect prothrombin test results led to several increases in his medication. He died shortly after of a brain hemor- rhage from over-medication.
• Over 100 patients tested positive for prostate cancer when in fact the test results from a prominent institution
were wrong and some patients un- derwent treatment for non-existent tumors. The problem was later de- termined to be errors by equipment, personnel, and procedures.
• As part of a routine military physical, a soldier was told he was HIV positive. This led to him and his wife separat- ing. Later the soldier found out he was actually HIV negative and the first test had been incorrect.
• A young couple was proud parents of a baby girl until routine tests cast doubt on the father’s paternity. The couple split up over this issue but reunited some years later and had another child. Knowing the first child wasn’t his, he insisted on a paternity test. They subsequently learned the first child was his and the original test had been compromised. In each of the four cases, something
went wrong between tests being ordered and clinicians acting upon results. And in each case, the errors led to traumatic ex- periences for the individuals and families involved, unintentional death, incorrect treatment, or the demise of a relationship. A diagnostic error is simply an incor- rect diagnosis of a patient condition and typically falls into one of four categories: error or delay in diagnosis, failure to
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