Almost daily we witness groundbreaking technologies and outstanding medical advancements that save patients’ lives. But from time to time, if you keep scrolling to the bottom of your feed, you might find a less positive article on medical errors…

From the misinterpretation of symptoms in ancient times to the infamous case of wrong-site surgery in the modern era, clinical errors have been part of doctor and patient lives from the dawn of medical history.  A famous example is the case from the 1980s, where a mix-up in the blood type of a patient led to a fatal transfusion reaction. This emphasized the importance of patient identification and blood type verification, followed by significant changes in healthcare practices, especially concerning infection control and patient safety. Another tragic occasion was the death of Libby Zion in 1984 due to a preventable drug interaction. The devastating results of this case led to a public debate around residents’ work hours and supervision, and then, changed it dramatically with new practices and guidelines that are known today as the “Libby Zion rules”.

But is it possible that today, after hundreds of years of practicing medicine we still face the same problem?

In recent decades we have seen an enormous investment in healthcare tech, new policies, training, and education, but yet, medical errors persist as a significant pain point. In today’s blog, I decided to focus on one aspect of the problem – the clinical decision-making process and how it is linked to medical errors, knowing that these errors are not anomalies but broader systemic issues that demand an innovative response from the healthcare community.

The Price of Errors: A System Under Strain

The impact of medical errors on the financial and operational aspects of the global health system has been substantial, highlighting the need for continuous changes to enhance patient safety. Direct annual cost of billions of dollars is added to litigation fees, extended hospital stays and lost productivity. Not to mention the emotional and physical impact on patients and their families. Recent research found that preventable medical errors lead to approximately 100,000 deaths each year in the United States alone!

The first step in fighting medical errors was developing clinical guidelines that incorporate evidence-based medicine (EBM) to standardize care and therefore, minimize errors. Unfortunately, variations in guidelines implementation contribute significantly to prevalence of medical errors. For instance, a study in Advances in Psychiatric Treatment detailed prescribing errors in a teaching hospital, underscoring the importance of clinical guidelines adherence in improving practices. Furthermore, another study emphasized the role of EBM in refining clinical decision-making. This approach helps integrate patient values with the best available scientific evidence, aiming to reduce practice variability and errors (Mandell, B. F., 2021).

Understanding the Spectrum of Clinical Decision-Making

Making clinical decisions is a highly complex process. Let’s use the emergency room as an example. It’s uncertain because patients come in for many different reasons, and there’s always a need for rapid assessment and action. Physicians and nurses in the ED are required to make quick, life-saving decisions often with limited information and under high stress. Recent studies have shown that this challenge is amplified by the hectic nature of the emergency room. In one study, the researcher explores how emergency care professionals make decisions in complex, uncertain situations³. It highlights that decision-making is often impacted by changing conditions and incomplete information. The research found that emergency department professionals frequently rely on their experience and intuition to make rapid decisions, emphasizing the critical role of intuitive thinking in emergency settings. Another paper underscores the high levels of uncertainty faced by nurses in emergency departments, affecting their decision-making processes ⁴. It points out that despite the advancements in medical technology and protocols, the dynamic and unpredictable nature of emergency care leaves nurses to make critical decisions under significant time pressure and with limited information. The review calls for improved support systems and training to help nurses manage uncertainty and enhance patient care outcomes.

This means that a critical pain point is clear: the high uncertainty and rapid decision-making requirements often lead to medical errors. The reliance on intuition and experience, while necessary, points towards a gap in systematic support and training, and emphasize even more the difference between seasoned and experienced physicians to young physicians at an earlier stage of their career. This environment requires enhanced protocols and decision support systems to mitigate the risk of errors and improve patient outcomes.

Paving a Path to Improvement

Leading the way in medical excellence are new and innovative strategies that aim to refine clinical decision-making and minimize clinical errors. Below are a few that are worth considering.

1. Integrating Decision-Support Systems: Decision-support systems (DSS) are revolutionizing clinical decision-making by providing healthcare professionals with critical, evidence-based information at the point of care. These systems leverage databases of medical knowledge and patient data to offer tailored recommendations, thereby reducing the likelihood of errors. For instance, electronic health records with embedded DSS tools can alert clinicians to potential drug interactions, recommend adjustments to drug dosages based on patient-specific factors, and highlight deviations from clinical guidelines.

2. Fostering Continuous Education and Training : Education plays a pivotal role in enhancing clinical decision-making. Continuous medical education programs, simulation-based training, and workshops focused on clinical guidelines and diagnostic tools ensure that healthcare professionals remain up to date.

3. Advancing Diagnostic Tools: The development of new diagnostic tools and technologies is critical in reducing clinical errors. From advanced AI-based imaging technologies that offer novel views of the human body, to point-of-care diagnostic tests that provide immediate results, and to host-response technologies that can translate signals coming from the immune system into clinical insights, these innovations aid in accurate diagnosis and treatment planning.

4. Promoting a Culture of Safety and Accountability: Creating a culture that prioritizes patient safety and accountability is essential in the fight against clinical errors. This involves implementing policies that encourage the reporting of errors and near-misses without fear of retribution, facilitating open discussions about mistakes, and learning from these incidents to implement systemic changes. Such a culture supports continuous improvement and helps to build trust among patients and healthcare providers.

5. Collaborative Efforts Across the Healthcare Spectrum: Reducing clinical errors and improving decision-making requires collaboration from different stakeholders in the health system: providers, patients, policymakers, and technology developers to ensure that the systems and tools developed are both effective and user-friendly. Engaging patients in their care decisions, for example, can help to ensure that treatments align with their values and preferences, further reducing the risk of errors.

Conclusion

Medical errors, and especially ones related to clinical decision-making have been a challenge from the earliest days of medicine until nowadays. Today, in this age of information and innovation, AI and advanced technologies are transforming this field. These provide healthcare professionals with unprecedented access to data and insights, enabling more accurate diagnoses, personalized treatment plans, and ultimately, safer patient outcomes.

Yet, the adoption of these technologies alone is not enough. A cultural shift within the healthcare industry is needed and healthcare providers, patients, and policymakers must collaborate to integrate these advancements effectively into daily practice, but the journey towards improving patient safety is a collective responsibility. It calls for a real commitment to education, innovation, and accountability. As members of the global healthcare community, we must seize the opportunities presented by modern technology and strive for a future where medical errors are not just reduced, but ideally, remain as an old memory.

References

1. Cohen S. The lasting legacy of a case that was “lost”. Penn State Law Review [Internet]. 2014 Sep 28 [cited 2024 Feb 27]. Available from: https://www.pennstatelawreview.org/penn-statim/the-lasting-legacy-of-a-case-that-was-lost/
2. Dean B, Schachter M, Vincent C, Barber N. Prescribing errors in hospital inpatients: their incidence and clinical significance. Qual Saf Health Care. 2002 Dec 1;11(4):340-4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1758003/
3. Franklin A, Gantela S, Shifarraw S, Johnson TR, Robinson DJ, King BR, et al. Dashboard visualizations: Supporting real-time throughput decision-making. J Biomed Inform. 2017 Jul 1;71:211-21. https://pubmed.ncbi.nlm.nih.gov/28579532/
4. Cranley L, Doran DM, Tourangeau AE, Kushniruk A, Nagle L. Nurses’ uncertainty in decision‐making: a literature review. Worldviews Evid Based Nurs. 2009 Mar;6(1):3-15. https://sigmapubs.onlinelibrary.wiley.com/doi/10.1111/j.1741-6787.2008.00138.x/
5. Mandell, BF. (2021). Evidence-Based Medicine and Clinical Guidelines. MDS Manual Professional Version [Internet]. 2022 [cited 2024 Feb 27]. Available from: https://www.msdmanuals.com/professional/special-subjects/clinical-decision-making/evidence-based-medicine-and-clinical-guidelines/
6. Gunderson CG, Bilan VP, Holleck JL, Nickerson P, Cherry BM, Chui P, et al. Prevalence of harmful diagnostic errors in hospitalised adults: a systematic review and meta-analysis. BMJ Qual Saf. 2020 Dec 1;29(12):1008-18. https://pubmed.ncbi.nlm.nih.gov/32269070/
7. Mazer BL, Nabhan C. Strengthening the medical error “Meme Pool”. J Gen Intern Med. 2019 Oct;34(10):2264-7. https://link.springer.com/article/10.1007/s11606-019-05156-7/
8. Zwaan L, Singh H. Diagnostic error in hospitals: finding forests not just the big trees. BMJ Qual Saf. 2020 Dec 1;29(12):961-4. https://pubmed.ncbi.nlm.nih.gov/32753410/