Skip to main content Accessibility help

We use cookies to distinguish you from other users and to provide you with a better experience on our websites. Close this message to accept cookies or find out how to manage your cookie settings.

Close cookie message
×
Hostname: page-component-cd9895bd7-fscjk Total loading time: 0 Render date: 2024-12-24T03:48:09.040Z Has data issue: false hasContentIssue false

4 - Impact of Medication Errors on the Patient and Family

Managing the Aftermath

Published online by Cambridge University Press:  09 April 2021

Alan Merry  and
Joyce Wahr
Alan Merry
Affiliation:
University of Auckland
Joyce Wahr
Affiliation:
University of Minnesota
Get access

Summary

The proportion of patients harmed by medication errors is small but when harm does occur it can be catastrophic, including death. The primary physical harm is only the tip of the iceberg as long-term psychological, emotional, and financial impacts are added to physical injury. These secondary effects are aggravated by failures to respond to adverse events in a caring, compassionate and transparent manner, fulfilling what we have called “the next promise”. The approach of the clinicians and institution involved in a harmful medication error is critical to recovery, and requires 1) full and transparent disclosure of all known causes for the error; 2) an apology that includes empathy and emotional support, a listening at length to the patients and their families without any attempt to deflect blame or downplay the impact; 3) appropriate and rapid compensation; 4) accountability; and 5) regular feedback to all regarding ongoing investigations into the event, and interventions that have been made to prevent this event happening to another patient. There is an excellent body of knowledge to guide institutions and their inter-professional clinical teams about how to design and implement a communication and resolution program that is ethical, patient centered and provides emotional support not only to patients and their families, but also to staff involved in the error.

Keywords

Preventable adverse eventpatient harmpsychological impactdisclosuretransparencyemotional distresscompassionretributionphysician empathyrestitutionfull disclosure
Type
Chapter
Information
Medication Safety during Anesthesia and the Perioperative Period , pp. 56 - 67
Publisher: Cambridge University Press
Print publication year: 2021

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Noble, DJ, Donaldson, LJ. The quest to eliminate intrathecal vincristine errors: a 40-year journey. Qual Saf Health Care. 2010;19(4):323–6.CrossRefGoogle ScholarPubMed
Merry, AF, Brookbanks, W. Merry and McCall Smith's Errors, Medicine and the Law. 2nd ed. Cambridge, UK: Cambridge University Press; 2017.Google Scholar
Bogod, D. The sting in the tail: antiseptics and the neuraxis revisited. Anaesthesia. 2012;1(12):1305–9.Google Scholar
Nathanson, MH. Guidelines on skin antisepsis before central neuraxial blockade. Anaesthesia. 2014;1(11):1193–6.Google Scholar
Sheather, M. Grace Wang: my epidural hell. Australian Women's Weekly. 2012. Accessed January 9, 2020. https://www.nowtolove.com.au/celebrity/celeb-news/epidural-victim-grace-wang-im-terrified-my-husband-will-leave-me-9747Google Scholar
Clinical Safety Quality and Governance Branch. Safety Notice 010/10. Correct identification of medication and solutions for epidural anaesthesia and analgesia. NSW Department of Health; 2010. Accessed January 9, 2020. https://www.health.nsw.gov.au/sabs/Documents/2010-sn-010.pdfGoogle Scholar
Swede asks for epidural and gets disinfectant. The Local. 2014. Accessed December 5, 2019. https://www.thelocal.se/20140813/pregnant-woman-treated-with-disinfectant-for-painsGoogle Scholar
Patel, S, Loveridge, R. Obstetric neuraxial drug administration errors: a quantitative and qualitative analytical review. Anesth Analg. 2015;121(6):1570–7.Google Scholar
Hatch, DM, Atito-Narh, E, Herschmiller, EJ, Olufolabi, AJ, Owen, MD. Refractory status epilepticus after inadvertent intrathecal injection of tranexamic acid treated by magnesium sulfate. Int J Obstet Anesth. 2016;26:71–5.CrossRefGoogle ScholarPubMed
Reason, J. The Human Contribution: Unsafe Acts, Accidents and Heroic Recoveries. Burlington, VT: Ashgate Publishing; 2008.Google Scholar
Perez, B, Knych, SA, Weaver, SJ, et al. Understanding the barriers to physician error reporting and disclosure: a systemic approach to a systemic problem. J Patient Saf. 2014;10(1):45–51.Google Scholar
Ottosen, MJ, Sedlock, EW, Aigbe, AO, et al. Long-term impacts faced by patients and families after harmful healthcare events. J Patient Saf. Published online January 17, 2018. doi:10.1097/PTS.0000000000000451Google Scholar
Gallagher, TH, Waterman, AD, Ebers, AG, Fraser, VJ, Levinson, W. Patients’ and physicians’ attitudes regarding the disclosure of medical errors. JAMA. 2003;289(8):1001–7.CrossRefGoogle ScholarPubMed
Kohn, LT, Corrigan, JM, Donaldson, MS, eds. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press, Institute of Medicine; 1999.Google Scholar
Committee Opinion No. 681 Summary: disclosure and discussion of adverse events. Obstet Gynecol. 2016;128(6):1461.CrossRefGoogle Scholar
Nitkin, K, Broadhead, L, Smith, L, Smith, P. No room for error. The Johns Hopkins Newsletter. January/February 2016. Accessed January 20, 2020. https://www.hopkinsmedicine.org/news/articles/no-room-for-errorGoogle Scholar
Wu, AW, Folkman, S, McPhee, SJ, Lo, B. Do house officers learn from their mistakes? JAMA. 1991;265(16):2089–94.Google Scholar
Hiatt, HH, Barnes, BA, Brennan, TA, et al. A study of medical injury and medical malpractice. N Engl J Med. 1989;321(7):480–4.Google Scholar
Safren, MA, Chapanis, A. A critical incident study of hospital medication errors. Hospitals. 1960;34:32–4.Google Scholar
Cooper, JB, Newbower, RS, Kitz, RJ. An analysis of major errors and equipment failures in anesthesia management: considerations for prevention and detection. Anesthesiology. 1984;60(1):34–42.CrossRefGoogle ScholarPubMed
Hilfiker, D. Facing our mistakes. N Engl J Med. 1984;310(2):118–22.Google Scholar
Boyle, D, O'Connell, D, Platt, FW, Albert, RK. Disclosing errors and adverse events in the intensive care unit. Crit Care Med. 2006;34(5):1532–7.Google Scholar
Petronio, S, Torke, A, Bosslet, G, et al. Disclosing medical mistakes: a communication management plan for physicians. Perm J. 2013;17(2):73–9.CrossRefGoogle ScholarPubMed
Duncan, EM, Francis, JJ, Johnston, M, et al. Learning curves, taking instructions, and patient safety: using a theoretical domains framework in an interview study to investigate prescribing errors among trainee doctors. Implement Sci. 2012;7:86.Google Scholar
Rosner, F, Berger, JT, Kark, P, Potash, J, Bennett, AJ. Disclosure and prevention of medical errors. Committee on Bioethical Issues of the Medical Society of the State of New York. Arch Intern Med. 2000;160(14):2089–92.Google Scholar
Lipira, LE, Gallagher, TH. Disclosure of adverse events and errors in surgical care: challenges and strategies for improvement. World J Surg. 2014;38(7):1614–21.Google Scholar
Cole, AP, Block, L, Wu, AW. On higher ground: ethical reasoning and its relationship with error disclosure. BMJ Qual Saf. 2013;22(7):580–5.Google Scholar
D'Errico, S, Pennelli, S, Colasurdo, AP, et al. The right to be informed and fear of disclosure: sustainability of a full error disclosure policy at an Italian cancer centre/clinic. BMC Health Serv Res. 2015;15(1):130.Google Scholar
Eadie, A. Medical error reporting should it be mandatory in Scotland? J Forensic Leg Med. 2012;19(7):437–41.CrossRefGoogle ScholarPubMed
Lehmann, LS, Puopolo, AL, Shaykevich, S, Brennan, TA. Iatrogenic events resulting in intensive care admission: frequency, cause, and disclosure to patients and institutions. Am J Med. 2005;118(4):409–13.Google Scholar
Schoen, C, Osborn, R, Huynh, PT, et al. Taking the pulse of health care systems: experiences of patients with health problems in six countries. Health Aff (Millwood). 2005;(suppl; web exclusives):W5-509-25.CrossRefGoogle Scholar
Etchegaray, JM, Ottosen, MJ, Dancsak, T, Thomas, EJ. Barriers to speaking up about patient safety concerns. J Patient Saf. Published online November 4, 2017. doi:10.1097/PTS.0000000000000334CrossRefGoogle Scholar
Nazione, S, Pace, K. An experimental study of medical error explanations: do apology, empathy, corrective action, and compensation alter intentions and attitudes? J Health Commun. 2015;20(12):1422–32Google Scholar
Hojat, M, Vergare, MJ, Maxwell, K, et al. The devil is in the third year: a longitudinal study of erosion of empathy in medical school. Acad Med. 2009;84(9):1182–91.Google Scholar
Neumann, M, Edelhauser, F, Tauschel, D, et al. Empathy decline and its reasons: a systematic review of studies with medical students and residents. Acad Med. 2011;86(8):996–1009.Google Scholar
Ferreira-Valente, A, Monteiro, JS, Barbosa, RM, et al. Clarifying changes in student empathy throughout medical school: a scoping review. Adv Health Sci Educ Theory Pract. 2017;22(5):1293–313.Google Scholar
Varjavand, N, Bachegowda, LS, Gracely, E, Novack, DH. Changes in intern attitudes toward medical error and disclosure. Med Educ. 2012;46(7):668–77.CrossRefGoogle ScholarPubMed
Horsburgh, M, Merry, A, Seddon, M, et al. Educating for healthcare quality improvement in an interprofessional learning environment: a New Zealand initiative. J Interprof Care. 2006;20(5):555–7.CrossRefGoogle Scholar
Moore, J, Bismark, M, Mello, MM. Patients’ experiences with communication-and-resolution programs after medical injury. JAMA Intern Med. 2017;177(11):1595–603.Google Scholar
Etchegaray, JM, Ottosen, MJ, Aigbe, A, et al. Patients as partners in learning from unexpected events. Health Serv Res. 2016;51(suppl 3):2600–14.CrossRefGoogle ScholarPubMed
Biermann, JS, Boothman, R. There is another approach to medical malpractice disputes. J Oncol Pract. 2006;2(4):148.Google Scholar
Kachalia, A, Kaufman, SR, Boothman, R, et al. Liability claims and costs before and after implementation of a medical error disclosure program. Ann Intern Med. 2010;153(4):213–21.CrossRefGoogle ScholarPubMed
Schwappach, DL. Frequency of and predictors for patient-reported medical and medication errors in Switzerland. Swiss Med Wkly. 2011;141:w13262.Google Scholar
McLennan, S, Shaw, D, Leu, A, Elger, B. Professional liability insurance and medical error disclosure. Swiss Med Wkly. 2015;145:w14164.Google Scholar

Save book to Kindle

To save this book to your Kindle, first ensure [email protected] is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about saving to your Kindle.

Note you can select to save to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be saved to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

Find out more about the Kindle Personal Document Service.

Available formats
×

Save book to Dropbox

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Dropbox.

Available formats
×

Save book to Google Drive

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Google Drive.

Available formats
×