Preventable Medical Errors in Healthcare
The frail elderly woman who experiences a 10-pound weight loss over two weeks while hospitalized for a CVA because she is unable to feed herself is a clear example of a preventable medical error. 1, 2
Understanding Preventable Medical Errors
The Institute of Medicine (IOM) defines a medical error as "the failure to complete a planned action as intended or the use of a wrong plan to achieve an aim." 1 Preventable medical errors are a significant cause of morbidity and mortality, with estimates suggesting they may account for as many as 44,000 to 98,000 deaths annually in the United States, making them the 8th leading cause of death—higher than motor vehicle accidents, breast cancer, or AIDS. 1
Classification of the Options
Let's analyze each option to determine which represents a preventable medical error:
GI bleeding from a non-steroidal medication: This is typically considered an adverse drug reaction or side effect rather than an error, especially if the medication was appropriately prescribed with known risks.
Patient reporting ototoxicity related to digoxin toxicity: Digoxin typically causes cardiac toxicity rather than ototoxicity (hearing damage). This represents a misunderstanding of medication effects rather than a preventable error.
Frail elderly woman experiences weight loss during hospitalization because she cannot feed herself: This represents a failure in the care delivery system to meet a patient's basic needs and is clearly preventable through proper nursing care and assistance.
Urinary incontinence after radical prostate surgery: This is a known potential complication of the procedure rather than an error in medical care.
Why Weight Loss in a Hospitalized Patient is a Preventable Error
The scenario of a frail elderly woman experiencing significant weight loss (10 pounds in two weeks) while hospitalized for a CVA because she cannot feed herself represents a preventable medical error for several reasons:
Failure of basic care: According to the IOM's definition of safe healthcare, this represents a failure to provide care that avoids injuries to patients from the care intended to help them. 1
System failure: This error reflects a breakdown in the healthcare delivery system rather than an unavoidable complication. The patient's inability to feed herself following a CVA is predictable, and systems should be in place to ensure adequate nutrition. 2
Preventability: Unlike surgical complications or medication side effects, weight loss due to lack of feeding assistance is entirely preventable through proper staffing, protocols, and attention to patient needs. 1, 2
Prevention Strategies
To prevent such errors, healthcare facilities should implement:
- Standardized nutritional screening and assessment protocols for all hospitalized patients, particularly those with conditions that may affect self-feeding ability 2
- Regular monitoring of patient weight and nutritional intake 2
- Clear communication and documentation of patients requiring feeding assistance 2
- Adequate staffing to ensure patients receive necessary assistance with meals 1
- Implementation of feeding assistance programs for patients identified as at-risk 2
Broader Context of Medical Errors
Medical errors represent a significant patient safety concern, with medication errors alone accounting for substantial preventable harm. 3, 4 However, errors of omission—such as failing to provide necessary care like feeding assistance—are equally important and often less visible in healthcare systems.
The American Academy of Pediatrics and other guideline societies emphasize that fostering a culture of safety, encouraging error reporting without blame, and identifying system vulnerabilities are essential to preventing medical errors. 2 These principles apply equally to errors of omission in basic care needs like nutrition.