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Systematic Review of Literature and Published Work on Medical Error Recovery

Author: Taiwo Akinwande, RN, BSN

Primary Advisor: Trevor Cohen, MBChB, PhD

Committee Members: Juliana Brixey, PhD, MPH, RN

Masters thesis, The University of Texas Health Science Center School of Health Information Sciences at Houston.

Abstract:

Medical error recovery can be accomplished by interrupting the error cycle through application of applicable error identification, detection, and corrective techniques and strategies. These strategies have been used successfully in other safety-critical domains (e.g. aviation, chemical, maritime, nuclear power plants, and process control industries), and with heavy costs associated with medical errors is therefore a need to put mechanisms in place to help in the discovery of impending medical errors as well as for timely recovery during or after the occurrence of medical errors .

The costs attributable to medical errors includes but are not limited to heavy financial costs (it is estimated to cost the United States $17-$29 billion per year [1]), the high mortality rate estimated to be attributable to preventable medical errors (according to one analysis, 48,000 to 98,000 Americans lose their life each year due to preventable medical errors), lost worker productivity, as well as loss of morale and trust in the healthcare system by the general populace [1].

This paper aims to review published research on medical error recovery; identify available error recovery methods that could be applied to mitigate severe medical errors occurring within the healthcare system; analyze the benefits derived from directing greater focus and resources on implementing medical error recovery methods (as compared with total medical error elimination that is presently yet to be achieved); and thereby employ evidence-based practice to provide medical error recovery solutions that contribute to improvements in patient safety. Medical error, which includes wrong surgical-site errors, improper use of restraints resulting in death or suicide, administering improper type and wrong blood products and dose of medications (otherwise referred to as adverse drug events), and failure to adhere to the “Six Rights” of medication administration (viz: Right Patient, Right Medication, Right Dose, Right Route, Right Time, Right Documentation), has been defined as ” failure of a planned action to be completed as intended, or the use of a wrong plan to achieve an aim” [1].

The purpose of this literature review is to aggregate research findings related to error recovery in medicine, analyze benefits accruing from implementing timely medical error recovery including promoting patient safety, as well as benefits derivable from directing greater focus and resources on implementing timely error recovery versus total elimination of all medical errors which is presently yet to be attained. This literature review contributes to the literature on error recovery by synthesizing current knowledge on the cognitive processes and patterns of progression in error management with an emphasis on error correction and recovery; and highlighting a research framework that integrates error recovery strategies employed by experienced practitioners in handling their own errors. The literature review is organized in accordance with models of recovery that have been developed in the context of high-reliability organizations(e.g. aviation, chemical, maritime, nuclear-power plants, and process control industries) in other domains (e.g. the works of Jens Rasmussen and Rene Amalberti and Tom Kontogiannis).