Chapter 3: Medical Errors, Adverse Events, and Human Factors

Background

Approximately 3.7% of patients hospitalized in New York State in 1984 suffered a disabling adverse event, two-thirds of which were preventable.¹ This data, published by Lucian Leape and colleagues in 1991, was startling to many and initiated widespread discussions about unintended patient harm. Indeed, many experts agree that the modern patient safety movement was conceived with the publication of this research in what became known as the Harvard Medical Practice Study. Leape would later say, “I recognized that my colleagues and I had uncovered a huge problem, but we had no idea what to do about it.”

So what Dr Leape did was to study the lessons from human factors engineering and cognitive psychology research regarding human error, culminating in a publication in JAMA in 1994 entitled “Error in medicine.”² If the Harvard study represented the conception of the modern day patient to safety movement, it is fair so say that “Error in Medicine” represents its birth.

In “Error in medicine,” Dr Leape reflects, “Can the lessons from cognitive psychology and human factors research that have been successful in accident prevention in aviation and other industries be applied to the practice of medicine? There is every reason to think they could be.” Leape concluded that errors must be accepted as evidence of systems’ flaws, not character flaws, and until and unless that happens, it is unlikely that any substantial progress will be made in reducing medical errors.² While 20 years later, there is still debate about whether or not substantial progress has been made in improving patient safety, one thing is certain: the healthcare industry has significantly deepened its understanding of human factors, medical error, and adverse events. This chapter provides an overview of these ongoing challenges and offers some suggestions regarding what to do about them.

No Data Without Story, no Story Without Data

The data disclosed in the Harvard Medical Practice Study were alarming. Behind each data point, however, there was a story. We know from experience that while data drives performance, stories drive engagement. In the spirit of “no data without a story, and no story without data,” here we provide several stories that have helped to engage the industry in performance improvement.

Just months after “Error in medicine” was published in JAMA, Cal Sheridan was born a healthy baby boy in a large accredited hospital where over 5500 newborns were delivered each year. The date was March 23, 1995. As his mother Sue tells the story, “Cal was first noted to be jaundiced through visual assessment at 16.5 hours old, but a bilirubin test was not done. He was discharged from the hospital when he was 36 hours and was described as having head to toe jaundice, but a bilirubin test was not done. Neither was his blood typed nor a Coombs test performed.”³