For years, experts have recognized that medical errors exist and compromise healthcare quality. Much has been written worldwide about medical errors and improvements in their reporting and handling, with the proposals ranging from the implementation of nationwide mandatory reporting with public release of performance data to voluntary reporting and quality-assurance efforts that protect the confidentiality of error-related data. In the present chapter, the author first points out the lack of standardized nomenclature and a universal taxonomy-classification for adverse events and medical errors, which complicates the development of a response to these issues. The chapter also reviews a number of methods of and adverse events’ and medical errors’ knowledge management, each of which has evolved over time and been adapted to different contexts. Finally, the author assesses each of these methods, unveiling their particular strengths and advantages, and also weaknesses and limitations.
Top1. Definitions And Context
The lack of standardized nomenclature and a universal taxonomy for adverse events and medical errors complicates the development of a response to the issues outlined in this paper. A number of definitions have been applied to medical errors and patient safety.
The World Health Organization (WHO) Collaborating Centres for International Drug Monitoring defines an adverse drug event as follows (WHO, 1984):
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Noxious and unintended and occurs at doses used in man for prophylaxis, diagnosis, therapy, or modification of physiologic functions.
In To Err is Human, the IOM adopted the following definitions:
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An error is defined as the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim.
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An adverse event is defined as an injury caused by medical management rather than by the underlying disease or condition of the patient
In an effort to thoroughly consider all of the relevant issues related to medical errors, the QuIC expanded of the IOM definition, as follows (QuIC, 2000):
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An error is defined as the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim. Errors can include problems in practice, products, procedures, and systems.
Top2. Classifications
Most people believe that medical errors usually involve drugs, such as a patient getting the wrong prescription or dosage, or mishandled surgeries, such as amputation of the wrong limb. However, there are many types of medical errors. The following seven categories summarize types of medical errors that can occur (Bates et al., 2003):