What is a medical error? This may seem like a question with a simple answer, but it’s not. Read these five scenarios and decide which ones are medical errors and which are not.

• Example #1: The patient you are caring for has been having lower leg pain and he is admitted to the hospital for diagnostic tests. The patient has history of hypertension. His blood pressure has been well controlled for many years by his anti-hypertensive medications, but because he has high blood pressure the physician has ordered routine blood pressure measurements: the physician has ordered measurements of the blood pressure every 12 hours, at 08:00 and 20:00. At 19:55 you begin to walk to the patient’s room to do a routine blood pressure measurement. But before you can get there another CNA calls for help; his patient has fallen and the CNA needs assistance. After helping your co-worker it is now 20:15 and you are 15 minutes late taking your patient’s blood pressure. Is that a medical error?

• Example #2: You are assigned to deliver a tube feeding to a patient through a PEG (Percutaneous endoscopic gastrostomy) tube. You wash your hands, you make sure the patient is sitting upright, you check to make sure the tube is open and clear, and you determine that there is not a large residual in the patient’s stomach: you perform the procedure in the way you have been taught and according to the rules of your workplace. You deliver the amount that was ordered at the proper rate and after the feeding has been delivered, you stay with the patient for 15 minutes to make sure she has tolerated the procedure. The patient seems to have tolerated the feeding, you make sure she has her call light within reach and leave the room. One hour later the patient vomits. The staff monitors the patient for the rest of the shift and she does not develop signs or symptoms of aspiration or harm from the vomiting. Is this a medical error?

• Example #3: You are caring for a patient who has had abdominal surgery two days ago. Her post-operative condition has been stable and she has had no complaints. However, at 22:30, 30 minutes before your shift is ending and while you are trying to “tie up loose ends” and prepare for shift change, the patient tells you she is having pain near the area of the surgical incision. She describes the pain as not too bad, a 4 on a 1-10 scale, and you do not check her vital signs or inspect the surgical dressing because the patient “doesn’t look very uncomfortable.” You are very busy and you forget to document what happened or tell your supervisor.

The next day when arrive at work you learn that during the night the patient’s

surgical incision had separated and she needed to go back to the operating room to

have the incision repaired. The patient lost blood and subsequently developed a

wound infection and a fever. When the CNA was asked why she did not report the

patient’s complaint, she admitted that she forgot to do so, but she also stated that

she did not know that pain at a surgical incision could indicate that the incision

might be separating. She thought that pain after an operation was “a normal

thing.” Is this a medical error?

• Example #4: You need to provide catheter care for a patient who has just been admitted. You wash you hands, put on latex disposable gloves, perform the procedure using proper technique, and document what you have done. Fifteen minutes later the patient develops hives and difficulty breathing. She requires oral diphenhydramine and intravenous epinephrine to treat the allergic reaction. Is this a medical error?

• Example #5: A CNA is caring for an elderly patient who has Alzheimer’s disease; he has taken care of this patient many times and knows her well. The patient can ambulate without assistance and she does not require a high level of physical care, but she frequently forgets where she is. She also has poor judgment in terms of her personal safety. Last week she left the hot water running in a sink for over five minutes and then tried to wash her hands and suffered first degree burns. The CNA checks the patient’s vital signs, irrigates her PEG tube, and then starts to leaves the room to check on another patient. Before the CNA leaves the room, the patient mentions that she needs to use the bathroom and she would like some help ass she is feeling a little weak today. The CNA tells the patient to wait; he will be back in five minutes to assist her. However, as soon as the CNA leaves, the patient wanders off to look for a bathroom (she forgets there is one in her room), mistakenly goes into an exit stairwell at the end of the hall, loses her balance on the steep steps and falls. She suffers broken hip. Is this a medical error?

If you read these examples quickly, you might think that all of them are medical errors but some are and some are not.

Example # 1: In the first example, the patient’s blood pressure is well controlled and has been stable. The measurements are considered routine and the patient did not suffer any harm from the delay, and he would not be expected to suffer any harm from a 15 minute delay in a blood pressure measurement that is scheduled once every 12 hours. Assisting the other CNA was a higher priority than rigidly following a schedule for a routine task. The 15 minute delay would not be considered a medical error.

Example #2: The CNA performed the tube feeding procedure correctly. No mistakes were made in the preparation, performance, or follow-up. Vomiting after a tube feeding is not unusual, it cannot always be prevented, and the patient did not suffer any harm. This is not a medical error.

Example #3: Clearly, the CNA made a mistake in not documenting or reporting the patient’s complaint. Separation of a surgical excision is considered to be a very serious problem with potential for harm, and the CNA should have known this. In this case, the error was preventable, the CNA lacked the proper knowledge, the CNA did not communicate important information, and the patient suffered harm. Pain is a common after a surgical procedure, but the CNA did not attempt to find out where the pain was or why the patient was having pain. She also did not report the patient’s complaint to her supervisor. This is a medical error.

Example #4: This is a medical error. The catheter care was performed correctly. But the CNA did not read the patient’s chart before doing the procedure so he failed to see the warning; the patient has a latex allergy. Whenever you are caring for a patient for the first time, it is advisable to check and see if the patient has any specific medical conditions or allergies that could impact the care. Also, latex allergies are relatively common and a medical professional should be expected to know this and plan accordingly. Never use a latex-containing product unless you are sure the patient does not have a latex allergy.

Example #5: This is a medical error. The CNA knew that the patient has Alzheimer’s disease, and he knew that she frequently became disoriented about where she is and that her judgment in terms of personal safety could not be trusted. The patient needed to use the bathroom, and the CNA seemed to rely on the fact that the patient would remember that there was a bathroom close by and that the patient would remember that he would be right back to help her use it. Given what we know about the patient, these are very poor assumptions and the patient’s injury is a direct result of this poor judgment. This is a medical error.

So, not everything that “goes wrong” in a health care setting is considered a medical error. Although many people have tried to define exactly what a medical error is, there is still no universal agreement on the term. In this module, a medical error will be defined as follows: