Preventable Medical Mistakes and the Role of Human Behavior

Malpractice events rarely involve “just one” error; in truth, one mistake often leads to a cascade of errors. Sometimes the errors are seemingly minor. Other times, the doctor and the team makes an error so egregious that it is almost inconceivable that it happened. These types of errors are referred to by the medical community as “never events.”

The term “never event” was introduced by Ken Kizer, MD in 2001. Kizer is the former CEO of the National Quality Forum (NQF). It refers to particularly shocking medical mistakes that should never happen. Mayo Clinic researchers selected 69 “never events” from more than 1.5 million surgical procedures performed over a five year period and they detailed why each error occurred. Researchers coded the human behaviors involved in order to identify the characteristics that contributed to the never event. They came up with 628 human factors that contributed to the mistakes and found that approximately four to nine of these factors were present per event and published a study in the medical journal Surgery.

The never events studied in the research study included:

• Performing the wrong procedure
• Wrong side or wrong site surgery
• Putting in the wrong implant
• Leaving an object inside of a patient

None of the preventable errors detailed in the study were fatal. When the researchers compared the rate of never events to nationwide medical error reporting based on data in the National Practitioner Data bank, they estimated the rate of never events in the United States is approximately 1 in 12,000 procedures.

In their investigation of these never events, researchers used human factor analysis which was developed to investigate military aviation accidents. There are four levels of errors that included dozens of human factors:

1. Pre-conditions for action, which encompasses distractions, stress, overconfidence and inadequate communications
2. Unsafe actions, including bending or breaking the rules and perceptual errors
3. Oversight and supervisory factors like inadequate supervision, staffing deficiencies and planning problems
4. Organizational influences, which are challenges with regard to organizational culture or processes

The researchers recommended systems approaches to improving communication, team composition and technology interfaces.

Preventable medical errors and medical malpractice lawsuits

Research published in the Journal of Patient Safety confirms that approximately 440,000 people die each year due to preventable medical errors making them the third leading cause of death and costing the United States billions of dollars every year.

Hopefully, studies like the one undertaken by researchers at Mayo Clinic will take place in health care settings all over the country and they will share their results so that the incidence of preventable errors and “never events” might be significantly reduced.