Health Care

Policy Adoptions to Reduce Medical Errors
Name
Institutional Affiliation
Policy Adoptions to Reduce Medical Errors
Introduction
The focus of the policy briefing memos is the medical errors that occur in the healthcare facilities thereby compromising the quality of life as well as the recovery process for the victims. The memo thus seeks to provide recommendations on the possible policies that the American College of Physicians can adopt to reduce the medical errors in the healthcare facilities.
Studies indicate that the underlying cause of the medical errors is the breakdown in the communication system among the various ranks of the members (Eaves-Leanos, & Dunn, 2012). The communication breakdown results in inadequate error reporting mechanisms leading to a repeat of the errors that endanger the well-being of the patients (Avery, 2012). The recommendation for the American College of Physicians is thus to eliminate the shame and blame mechanisms in the traditional means of handling errors and thus adopt a reporting mechanism that will allow the concerned personnel to learn from the errors (Silow-Carroll et al., 2007).
Background and Context
The 1999 release of the publication ‘To err is human: Building a safer health system’ by the National Academy of Medicine brought to the attention of the public the extent of medical errors as well as the implication to human life. According to the publication, medical errors cost the lives of between 44,000 and 98,000 individuals each year (Bleich, 2005).

Further, the general report from the department of health and human services found that approximately 180,000 Medicare beneficiaries fell victim to the adverse effects of medical error resulting in the loss of their lives in addition to a rise in government spending on healthcare by $ 4.4 billion. The resultant cost of medical provision by the government presents an issue of concern thus the relevance of policy recommendations to minimise medical errors.
Relevance to Public Policy
Medical error is a public policy concern because of the human and well as monetary costs that affect the government and the society (American College of Physicians, 2016). Conversely, medical error handicaps the functioning of the society by causing not only the loss of lives and possible lifelong injuries but also unnecessary spending the rectifying the damage, funds that could contribute to other sectors of national development (Harvard Kennedy School, 2018).
Key Stakeholders
While the primary victim of medical errors in the healthcare systems is the patient, the individuals surrounding the patient also suffer from the implications of medical error (Millenson, 2002). The individuals include close family members who are benefactors to the patient or beneficiaries from the patient’s contribution to society. Further, the patients incur medical expenses as an outcome of medical error. Thus, the insurance organisations that cover medical care represent a separate category of stakeholders in managing medical errors and their implications to individual families and the society.
The primary stakeholder in the entire process is the government. Through government efforts such as Medicaid, the implications are direct and significant with costs of up to 4.4 billion dollars in managing the effects of medical error (Gitterman, 2017). The secondary implications for the government as a stakeholder include the implication that medical error presents to human resource in different errors of the economy (Levine, 2009). The deaths and injuries resulting from medical error affect the economic and production capacity of the government.
Political, Economic, and Legal Factors
The political factors in medical errors revolve around policy recommendations to manage the situation in addition to the adoption of the policy recommendations by different public and private healthcare facilities. Each facility has its unique set of governance in addition to standard operating procedures (SOPs). Therefore, the politics of the organisations influence the measures to curb medical error.
On the other hand, medical error presents a significant challenge to the economic systems. The first consideration is the additional costs that go into alleviating the implications of medical errors (Liang, 2002). Further, medical errors often result in the deaths and sometimes the loss of function for non-disabled individuals. The outcome is the economic disempowerment of the said individuals which results in their economic dependency on other members of the society due to their loss of productivity.
A final consideration in medical errors is the implication in the legal system. Often, once the stakeholders identify the medical errors as well as their source, the result is litigation measures directed against the facilities and individual practitioners. The judicial system would thus contribute to measures that ensure effective identification as well as management of medical errors.
Options
It is apparent that the traditional methods of addressing medical errors that include shaming and blaming are inefficient in handling the issue (Lamb et al., 2002). In fact, the shame and blame measures result in fear among the practitioners and thus, minimal reporting of the errors (Wright, 2010). It is also evident that while the errors are unavoidable, the least the practitioners can do is to learn from the errors (World Health Organization, 2008).
Therefore, the first option for addressing the issue involves abolishing the shaming and blaming process and replacing it with accountability measures where the entire institution is accountable for a medical error even if the origin is a single practitioner. That way, medical practitioners and nurses will be responsible for each other, and instead of ignoring or covering up the medical issues, they would countercheck each other’s work to ensure accuracy in delivery.
A separate alternative involves adopting effective reporting mechanisms in which the practitioners will have the confidence to include the possible error in their reports (Kraman, & Hamm, 1999). The reporting will notify the entire system of the error process including its origin and the measures to avoid it in future.
ConclusionA measure I recommend towards reducing medical errors in the healthcare facilities is the abolishment of the shame and blame means and replacing the process with equal accountability for all members of staff. Errors may be human, but they also occur because of societal segregation in which individuals isolate each other. An illustration is the hospital administrator overlooking the fact that a physician has been on shift for extra hours and required rest (Adams et al., 2000). An error from the overworked physician will be as much their doing as it is the fault of the administrator (Tsigaa et al., 2017). Subsequently, all members or stuff become responsible for a medical error.
Thus, equal accountability will allow teamwork that will minimise the medical errors. In summary one the medical practitioners understand that an error from one of them impacts the entire establishment, there will be an increased willingness to oversee the operations of their colleagues (Crowley, 2017). Besides, the practitioners will have concern for each other’s capacity to effectively perform medical processes and operations for the safety of the patients and the integrity of the entire healthcare facility.
References
Adams, C., Krieger, L., Luciano, L., Paul, C., Rebillot, K., Reese, S., Roessner, J. and Ziegler, J., (2000). Reducing Medical Errors and Improving Patient Safety; Success Stories from the Front Lines of Medicine. National Coalition on Health Care and the Institute for Healthcare Improvement, W.K. Kellogg Foundation of Battle Creek, Michigan.
American College of Physicians. (2016). Policy Compendium; Summer 2016. The American College of Physicians Division of Government Affairs, Public Policy 25 Massachusetts Ave NW, Suite 700 Washington, DC 20001
Avery, T., (2012). Investigating the prevalence and causes of prescribing errors in general practice:. Division of Primary Care, School of Community Health Sciences, University of Nottingham.
Bleich, S., (2005). Medical Errors: Five Years After the IOM Report. The Commonwealth Fund/John F. Kennedy School of Government, Bipartisan Congressional Health Policy Conference.
Crowley, R. A., (2017). Patient Safety in the Office-Based Practice Setting. American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106
Eaves-Leanos, A. & Dunn, E. J., (2012). Open Disclosure of Adverse Events: Transparency and Safety in Health Care. Elsevier Inc, Surg Clin N Am 92 (2012) doi:10.1016/j.suc.2011.11.001 s pages 163–177
Gitterman, D. P., (2017). Calling the Shots: The President, Executive Orders, and Public Policy. Brookings Institution Press, Political Science – 304 pages.
Kraman, S. & Hamm, G. (1999), Risk Management: Extreme Honesty May Be the Best Policy, Annals of Internal Medicine 31, no. 12, Pages 963–967.
Lamb, R., Studdert, D., Bohmer, R., Berwick, D. & Brennan, T., (2002). Hospital Disclosure Practices: Results Of A National Survey. Project HOPE–The People-to-People Health Foundation, Inc HEALTH AFFA IRS ~ Vo l u m e 2 2 , N u m b e r 2, pages 73-83.
Levine, R., (2009). Shock Therapy for the American Health Care System: Why Comprehensive Reform is Needed. ABC-CLIO, 2009 – Health & Fitness – 186 pages.
Liang, B. A., (2002). A system of medical error disclosure. Southern Illinois University School of Law and School of Medicine, 1150 Douglas Drive, Carbondale, IL 62901-6804, USA, Qual Saf Health Care 2002;11: pages 64–68.
Millenson, M. L., (2002), Pushing the Profession: How the News Media Turned Patient Safety into a Priority, Quality and Safety in Health Care 11, no. 1 (2002): pages 57–63.
Silow-Carroll, S., Alteras, T. & Meyer, J., (2007). Hospital Quality Improvement: Strategies And Lessons From U.S. Hospitals. Health Management Associates, Commonwealth Fund pub. no. 1009
Tsigaa, E., Panagopouloua, E. & Montgomery, A., (2017). Examining the link between burnout and medical error: A checklist approach. Burnout Research Volume 6, September 2017, Pages 1-8
World Health Organization. (2008). Learning From Error; Patient Safety Workshop. World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland.
Wright, S., (2010). Memorandum Report: Adverse Events in Hospitals: Public Disclosure oj Information About Events, OEI-06-09-00360. Department Of Health & Human Services, Washington, D.C. 20201.