Errors in medicine.

Modern awareness of the problem of medical injury--complications of treatment--can be fairly dated to the publication in 1991 of the results of the Harvard Medical Practice Study, but it was not until the publication of the 2000 Institute of Medicine (IOM) report, To Err is Human that patient safety really came to medical and public attention. Medical injury is a serious problem, affecting, as multiple studies have now shown, approximately 10% of hospitalized patients, and causing hundreds of thousands of preventable deaths each year. The organizing principle is that the cause is not bad people, it is bad systems. This concept is transforming; it replaces the previous exclusive focus on individual error with a focus on defective systems. Although the major focus on patient safety has been on implementing safe practices, it has become increasingly apparent that achieving a high level of safety in our health care organizations requires much more: several streams have emerged. One of these is the recognition of the importance of engaging patients more fully in their care. Another is the need for transparency. In the current health care organizational environment in most hospitals, at least six major changes are required to begin the journey to a culture of safety: 1. We need to move from looking at errors as individual failures to realizing they are caused by system failures; 2. We must move from a punitive environment to a just culture; 3. We move from secrecy to transparency; 4. Care changes from being provider (doctors) centered to being patient-centered; 5. We move our models of care from reliance on independent, individual performance excellence to interdependent, collaborative, interprofessional teamwork; 6. Accountability is universal and reciprocal, not top-down.

A fatal device-device interaction between a wearable automated defibrillator and a unipolar ventricular pacemaker.

We report a fatal device-device interaction between a wearable automated defibrillator (WAD; LifeVest - LifeCor, Inc., Pittsburgh, PA, USA) and a unipolar pacemaker that occurred in an 18-year-old patient listed for cardiac transplantation due to his failing Fontan. The patient developed ventricular tachycardia that was initially detected by the WAD. However, large unipolar pacing artifacts and specific WAD arrhythmia detection algorithms caused the WAD to revert to nonrecognition of the arrhythmia, which lead to the patient's death. We identify likely causes of the failure and suggest methods of preventing such occurrences in the future.

Defibrillation coil reversal: a rare cause of abnormal noise and inappropriate shocks.

We report a rare case of inadvertent reversal of the defibrillator shock coils during generator change which then resulted in both intermittent, recurrent "noise" on both the rate sensing and the shock electrogram leads and multiple inappropriate shocks.

Accidental intraneural injection into the musculocutaneous nerve visualized with ultrasound.

Ultrasound has become a widely used tool within the practice of regional anesthesia, offering real-time visualization of the nerves, needle, and local anesthetic during performance of a block. A successful ultrasound-guided axillary block was performed on a healthy adult male undergoing wrist surgery. Postoperative review of the ultrasound video recording of the block suggested that an intraneural injection had occurred during the procedure. The patient had an effective block and suffered no adverse neurological effects. Recording and reviewing ultrasound images of a regional block can be important for documentation and educational purposes.

Loss of the guide wire: a case report.

A case of a lost guide wire extending from the vena cava to the back of the neck after central venous catheterization is presented. A trainee inserted a central venous catheter via the left subclavian vein in a 40-year-old male patient after surgery, but did not notice that a guide wire was completely inserted in the vein. After 6 months, the lost guide wire was seen extending from the saphenous vein through the vena cava, right atrium, right ventricle, pulmonary artery and lung tissue to the back of neck. Although percutaneous catheterization of central veins is a routine technique, it is a procedure requiring advanced surgical skills, expert supervision, and attention to detail in order to prevent adverse effects. The present case is not only a technological problem, but also one of responsibility. The operator must hold onto the guide wire at all times until removal from the vessel, and a supervisor must make sure that trainees are aware of all possible complications.

A case study in medical error: the use of the portfolio entry.

The Accreditation Council for Graduate Medical Education (ACGME) Practice-Based Learning and Improvement competency incorporates lifelong learning techniques and self-reflection. Resident portfolios have received attention as a useful method for addressing this competency. A recent patient encounter provided an experienced clinical educator with the opportunity to develop a portfolio entry that was distributed to all of the residents and faculty in an emergency medicine residency. This report may assist educators in explaining how one could approach the development of the portfolio as a tool for self-assessment. A candid discussion by a senior faculty member about issues that contributed to medical error has been underreported in the medical literature.

An analysis of medical device-related errors: prevalence and possible solutions.

The UK and USA are currently undergoing a period of considerable change in their attitude towards medical error and their understanding of its causes and magnitude. In both countries, with increasing rapidity, a disturbing situation is being revealed. This paper presents the results of an investigation into medical errors in the UK and the USA, and focuses in particular on the magnitude and causes of errors when using medical devices. Contrary to the traditional approach of blaming users, it is suggested here that many such errors are caused partly by poor device design, which fails to account adequately for the needs of users. In response, this paper also discusses the basics of a Human Factors Engineering (HFE) approach as a step towards overcoming this problem and offers a challenge to device users and design companies (manufacturers) to follow HFE principles in order to improve the efficiency of operation and reduce errors during device use.

TG-51: experience from 150 institutions, common errors, and helpful hints.

The Radiological Physics Center (RPC) is a resource to the medical physics community for assistance regarding dosimetry procedures. Since the publication of the AAPM TG-51 calibration protocol, the RPC has responded to numerous phone calls raising questions and describing areas in the protocol where physicists have had problems. At the beginning of the year 2000, the RPC requested that institutions participating in national clinical trials provide the change in measured beam output resulting from the conversion from the TG-21 protocol to TG-51. So far, the RPC has received the requested data from approximately 150 of the approximately 1300 institutions in the RPC program. The RPC also undertook a comparison of TG-21 and TG-51 and determined the expected change in beam calibration for ion chambers in common use, and for the range of photon and electron beam energies used clinically. Analysis of these data revealed two significant outcomes: (i) a large number (approximately 1/2) of the reported calibration changes for photon and electron beams were outside the RPC's expected values, and (ii) the discrepancies in the reported versus the expected dose changes were as large as 8%. Numerous factors were determined to have contributed to these deviations. The most significant factors involved the use of plane-parallel chambers, the mixing of phantom materials and chambers between the two protocols, and the inconsistent use of depth-dose factors for transfer of dose from the measurement depth to the depth of dose maximum. In response to these observations, the RPC has identified a number of circumstances in which physicists might have difficulty with the protocol, including concerns related to electron calibration at low energies (R50<2 cm), and the use of a cylindrical chamber at 6 MeV electrons. In addition, helpful quantitative hints are presented, including the effect of the prescribed lead filter for photon energy measurements, the impact of shifting the chamber depth for photon depth-dose measurements, and the impact of updated stopping-power data used in TG-51 versus that used in TG-21, particularly for electron calibrations.

Long-term central venous catheterization via persistent left superior vena cava: a case report.

We report a case of a cancer patient who displayed a persistent left superior vena cava (PLSVC) after implantation of a central venous catheter (Port-a-Cath), as revealed by angiography. This anomaly is rather rare (0.3% of healthy individuals), and the few studies on the long-term maintenance of an implant in situ are not very informative. Nevertheless, based on the acceptable venous caliber and the patient's serious clinical situation, we decided to leave the catheter in place and perform infusional chemotherapy and supportive therapy with careful and continuous control. The patient died after 8 months of this therapy. No complications attributable to the catheter were observed. We think that the risk is acceptable in similar conditions.