There has been a wealth of publicity surrounding preventable medical errors, including the Institute of Medicine report (1) which stated that up to 98,000 people die each year in the US from such errors. This book, published in 2000, drew upon earlier studies, including a New England Journal of Medicine study from 1991 (2).
Medical errors are not just reported in medical journals, but also in popular media. Examples include the health reporter for the Boston Globe, Betsy Lehman, who died from an overdose during chemotherapy and Willie King who had the wrong leg amputated. When I talk to people about wrong site surgery, they often recall an experience about someone they knew who had surgery and was repeatedly asked about the surgery site to confirm its correctness.
Since then, with all of the public awareness and regulatory programs, is the rate of preventable medical errors improving? A recent article suggests that the answer is no, at least for wrong site surgery. Lauran Neergaard, an AP medical writer noted in a June 22, 2004 article (3) that according to JCAHO, since 1999 there have been 275 cases of wrong site surgery – “a steady increase each year and a problem it calls undoubtedly undercounted”. It’s hard to imagine that the number is this high for this type of error but it is.
FMEA and RCA
FMEA (Failure Mode Effects Analysis) and RCA (Root Cause Analysis) represent techniques to deal with potential errors (FMEA) and observed errors (RCA). One does not want “to observe” the event wrong site surgery – hence FMEA is a more appropriate tool.
- An electronic summary is available here.
- Brennan, Troyen A.; Leape, Lucian L.; Laird, Nan M., et al. Incidence of adverse events and negligence in hospitalized patients: Results of the Harvard Medical Practice Study I. N Engl J Med. 324:370376, 1991. See also: Leape, Lucian L.; Brennan, Troyen A.; Laird, Nan M., et al. The Nature of Adverse Events in Hospitalized Patients: Results of the Harvard Medical Practice Study II. N Engl J Med. 324(6):377384, 1991
- See: http://msnbc.msn.com/id/5264092/