Sometimes they are concatenations of small individual errors, sometimes the failure of individuals or certain control mechanisms – treatment errors in the medical field occur frequently. Thanks to an initiative of the Patient Safety Action Alliance, openness is entering the discussion.
Dealing openly with treatment errors
A classic case: a nurse on the night shift was monitoring a patient whose upper airway needed regular suctioning after total gynecological surgery and a tracheotomy. The ward was hectic, with many patients needing help. “When changing the infusion bottle, I have to re-fix the indwelling cannula in the gynecological patient. Other patients are ringing and calling. I get caught up in the hustle and bustle and forget the fixation patch I prepared…”.
A mistake: The patient “… lies lifeless and blue-marbled in bed. The bell had slipped out of her reach. – She had pulled the cut fixation plaster from the infusion stand over the cannula stuck in her trachea and suffocated.” (from: Aktionsbündnis Patientensicherheit e.V.: Learning from Mistakes, p. 8).
17 authors report on their professional treatment errors in the brochure Learning from Mistakes. The chairman of the Patient Safety Alliance, Matthias Schrappe, who published the brochure in early 2008, called for an open approach to so-called malpractice: “Only if we talk about mistakes can we prevent them.”
Schrappe himself also admits to mistakes. As a young resident, he had not immediately recognized that a patient with a racing heart and restlessness was suffering from a pulmonary embolism. His boss didn’t care about the near-miss at the time. Patient safety has become an important issue for the AOK, for example, co-editor of the brochure Learning from Mistakes.
On its website, it assumes that with more than 17 million treatments per year in German hospitals, up to 1.7 million patients have been “victims of adverse events.” Nevertheless, patient safety has so far usually only become a public issue when, for example, the wrong leg has been amputated.
What is a treatment error?
According to the German Patient Safety Action Alliance, approximately 17,000 people die each year in Germany as a result of preventable errors in hospital treatment, one in every thousand hospital patients – most of them infections due to poor hygiene and side effects of drugs.
A treatment error is defined as an inappropriate, for example, not careful, not correct or not timely treatment of a doctor and can affect all areas of medical activity – this includes action or omission. The error may be of a purely medical nature, may relate to organizational issues, or may involve errors by subordinate or ancillary persons such as nurses.
Missing or incorrect, incomprehensible or incomplete information about medical interventions and their risks also count as treatment errors. According to the Medical Service of the Health Insurance Funds (MDK), around 40,000 patients complain each year because they believe they have been harmed by a treatment error.
