About 5 years ago, I wrote an article for the WAVE on this subject based on a patient of mine who experienced a serious medical error while under my care at a SNF.  As I reflect on that case, I  recall that I immediately sought advice from the referring colleague and from a trusted colleague.  I then reported the error to the administration and was relieved that they supported full disclosure.  I disclosed the serious medication error to the patient and his wife with sensitivity, but the experience was emotionally traumatic for them and those involved with their care.  In retrospect, our response was reactive and done without the support of HR, clinical psychologist, risk management, or the counsel of our liability carriers.  

For this reason, I read the January 13, 2024, NEJM article, “Responding to Medical Errors-Implementing the Modern Ethical Paradigm,” with great interest.  This article is available at no charge on NEJM with the option for signing up for other future articles on a limited basis.   This article presents the CRP (Communication and Resolution Programs) Model for Responding to Harmful Medical Errors.  I wish I’d had the helpful action grid when I responded to the above serious medical error (grid available with NEJM article).  

In 1999, the Institute of Medicine published the shocking report labeled “To Err Is Human” (To Err is Human: Building a Safer Health System - PubMed (nih.gov) that claimed at least 100,000 deaths/year in the USA were caused by medical errors.  Subsequent investigations have reported much higher annual death rates.  I suspect the rate of serious medical errors may be higher in the SNF setting where we don’t have as robust systems for preventing medical errors as do our acute hospital partners.  This is an article on common medication errors in nursing homes from 2021 (Medication Errors in Nursing Homes - Know the Standards (nursinghomeabusecenter.com)

Acute hospitals have adopted policies and procedures that encourage the reporting of medical errors, and many have adopted processes for responding to medical errors that are transparent and minimize the harms to patients, staff, the hospital, their liability partners, and those who oversee their care.  

Will 2024 be the year that your facility adopts a more robust and effective response to identifying, reporting, and responding to medical errors?