What is an example of a medical error?

Medical Errors: Understanding Management Plans Not Completed as Intended

Management plans not completed as intended are a type of medical error, as they represent a failure in the treatment process that can lead to patient harm.

Definition of Medical Error

Medical errors are failures in the treatment process that lead to, or have the potential to lead to, harm to the patient 1. They represent a serious public health problem and pose a significant threat to patient safety 2.

Medical errors can occur at various stages of the healthcare process:

• Prescribing stage: Irrational prescribing, inappropriate dosing, or ineffective prescribing 1
• Dispensing stage: Wrong drug, wrong formulation, or wrong label 1
• Administration stage: Wrong dose, wrong route, wrong frequency 1
• Monitoring stage: Failing to alter therapy when required 1
• Implementation stage: Management plan not completed as intended 3

Types of Medical Errors

Medical errors can be classified into several categories:

1. Medication errors: These include errors in prescribing, dispensing, and administering medications 3

   • 5.7% of medication orders in pediatric hospitals contain errors 3
   • 35% of medication errors occur at the administration stage 3

2. Diagnostic errors: These include delays in diagnosis, missed diagnoses, or incorrect diagnoses 3

   • 7% of errors in NICUs involved delays or errors in diagnosis 3

3. Communication errors: These include failures in communication between healthcare providers or between providers and patients 4

   • Verbal communication of critical laboratory results can lead to errors, especially when proper verification procedures are not used 4

4. Management plan errors: These occur when a planned treatment or intervention is not completed as intended 3

   • This can include failure to follow protocols, omission of ordered tests, or incomplete implementation of care plans

Why Management Plans Not Completed as Intended Are Medical Errors

Management plans not completed as intended represent a significant category of medical errors for several reasons:

1. System failures: They often result from system failures rather than individual negligence 3

   • The American Academy of Pediatrics emphasizes improving systems rather than blaming individuals 3

2. Potential for harm: Even when no immediate harm occurs, these errors indicate system vulnerabilities that could lead to serious adverse events in the future 3

3. Prevalence: Studies have shown that management plan errors are common in both inpatient and outpatient settings 3

   • In the Learning From Errors in Ambulatory Pediatrics study, 37% of errors were attributed to medical treatment 3

4. Preventability: Most management plan errors are considered preventable with proper systems and protocols in place 3

Distinguishing Between Error Types

It's important to understand that:

• A medical error is a failure in the treatment process, which includes management plans not completed as intended 1
• Negligence is a specific type of error involving a breach of the standard of care that results in harm 2
• A mistaken diagnosis or prescription is a specific type of error related to clinical decision-making 1

Prevention Strategies

To prevent management plan errors and other medical errors:

1. Implement standardized protocols: Use structured communication tools like SBAR (Situation, Background, Assessment, Recommendation) 4

2. Foster a culture of safety: Encourage error reporting without blame to identify system vulnerabilities 3, 4

3. Utilize technology: Implement electronic systems that flag abnormal values and require acknowledgment 4

4. Improve communication: Require read-back verification for critical information and orders 4

5. Regular training: Conduct systematic reviews of near-misses and actual errors to identify areas for improvement 4

By understanding that management plans not completed as intended constitute medical errors, healthcare systems can work toward implementing effective prevention strategies and improving patient safety.