Eminè Meral Inelmen, Enzo Manzato
Dipartimento di Scienze Mediche e Chirurgiche
Cattedra di Geriatria (Direttore: E. Manzato)
Università degli Studi di Padova
Although medical error (ME) is a public health burden (1),
instead of learn and prevent, we often use to hide this problem.
We found that it is too easier to accept some degree of MEs
as the inevitable product of today's increasingly complex
patient care, rather than exploring why the error occurred.
Because of the fear of lawsuits, of humiliation, of job loss
we prefer not to talk about this topic. In fact, the public
believes that doctors responsible for errors with serious
consequences should be sued, fined, and even subject to suspension
of their professional license (2). Thus, when ME occurs, the
reaction in medical settings is most commonly an attempt to
fix blame and to punish someone (3). Fear, reprisal, and punishment
produce not safety, but rather defensiveness, secrecy, and
enormous human anguish (3).
The risk of MEs is not the same in all cases: the sickest
patients who are subjected to multiple interventions, and
who remain in hospital longer, are more likely to suffer serious
injury as a result of medical mistakes (4); so it is reasonable
to conclude that errors are committed more frequently in the
geriatric field (1). Sadly, diagnostic errors have received
little attention in literature, especially in geriatrics,
although the elderly population has been increasing in the
last few decades (1).
Here we focus attention on this alarming issue and stress
the need of creating strategies against MEs in geriatrics.
EPIDEMIOLOGY OF THE MEDICAL ERRORS
In the last decades we are seeing MEs as an "epidemic"
condition (1). One million injuries and nearly 1000.000 deaths
seem to occur in the United States annually as a result of
mistakes in medical care (5). It is as a jumbo crash occurs
every two weeks in one year! In fact, one estimate is that
a modern passenger would have to fly continuously for 2O.OOO
miles in order to reach a 50% chance of injury in an airplane
accident (3). Actually there is no way of knowing exactly
how many people died from a particular procedure. There are
still no codes for MEs.
POSSIBLE CAUSES OF MEDICAL ERRORS
Blendon et al. (2), conducted a survey on the possible causes
of MEs: understaffing of nurses in hospitals and overwork,
stress, or fatigue on the part of health professionals were
the two main causes reported by physicians, while the top
four causes considered to be very important by public were
physicians' not having enough time with patients; overwork,
stress, or fatigue on the part of health professionals; failure
of health professionals to work together or communicate as
a team; and understaffing of nurses in hospitals.
Work-loads of healthcare staff has to be avoided: safe performance
cannot be expected from workers who are sleep deprived, who
work double or triple shifts
(6). After 24 hours of work without sleeping , the capacity
of a healthcare operator is similar to a drunk person! (7).
POSSIBLE CAUSES OF MEDICAL ERRORS IN GERIATRICS
Achieving an accurate clinical diagnosis is especially difficult
in elderly patients, many of whom will have multiple pathology
and whom presentation of disease may be atypical. Each older
patient often has a different and very complex clinical scenario.
Accuracy of clinical diagnosis declined with increasing patient
age, so that only 47 % of clinical main diagnosis were confirmed
at necropsy in 295 patients aged more than 75 years old (8).
For example, the diagnosis of appendicitis in elderly is not
always easy. Especially in demented, non collaborating, bedridden
elderly patients, medical history or physical examination
may lead to misdiagnosis because they can be incomplete, poorly
performed, or wrongly interpreted (1). In addition, excessive
reliance on laboratory test results may cause confusion because
of the co-morbidities (1). The most misleading symptoms in
elderly are vertigo, imbalance, falls, disorders of consciousness.
Hence, in geriatrics the clinical diagnosis is not always
the aim: we often cure only the symptoms for which the patient
has been recovered. Because of the large use of drugs and
the occurrence of interactions we can err in the treatment.
In fact, adverse effects of drugs are very frequent in advanced
age; although iatrogenic injuries observed in autopsies are
frequent cause of death, approximately 90 % of them are not
described in clinical reports (9). Inappropriate invasive
diagnostic procedures can be also considered as errors, as
they can harm the old patient without any benefit.
A study based on autopsy of 311 subjects has shown that patients
with obese-level BMIs seem to be at increased risk for clinically
unsuspected diagnoses, compared with underweight and normal
weight populations (10). As obesity is becoming an "epidemic"
condition at all ages (11), misdiagnosis is supposed to increase
in the future because of both increases of elderly and obese
It is interesting to note that there is a greater accuracy
of diagnosis in the elderly by specialist geriatricians compared
with non-specialist units, although the levels of misdiagnosis
are still high (12).
REPORTING MEDICAL ERRORS
The great problem of not having the precise prevalence and
magnitude of ME, even if it is probably enormous, is the under-reporting
of errors (4). Universal under-reporting undermines the ability
to measure error accurately (4). But who is responsible of
reporting MEs? We are supposed to be the reporters but we
are afraid of being sued so usually it is the patient or the
patient's surviving family. If no one notices the error, it
is never reported.
We should learn error-reporting in our training and use it
but, unfortunately, the problem is not only to be educated
to report MEs. In USA some states have mandatory reporting
programmes for error resulting in serious patient harm (13),
but this information is used almost exclusively to punish
individual practitioners or healthcare organisations (5).
Reporting will occur only if practitioners feel safe doing
so and becomes a culturally accepted activity within the healthcare
community (13). We need freedom from punishment, which is
possible only with a voluntary reporting programme (13). We
should like to tell anyone about our bad mistake but we are
afraid of patient's anger and worse than this, of court punishment.
To report in this way can be compared to a "liberator
confession". If we will "confess" we can avoid
to be "the second victim", as Wu (14) calls, feeling
the sense of guilt or remorse. Hence, we need a legal protection
if we are supposed to report our error. Buetow (15) suggested
that patients "make errors too" and they have to
be considered "morally" responsible of their errors:
in fact, they may forget to do certain things, such as attend
for a planned therapies, or fail to read medication labels
and instructions carefully. This can be more frequent among
elderly patients who are not able to read because of visual
reduction or because of cognitive decline.
AUTOPSY: A WEAPON AGAINST MEDICAL ERRORS
There exists a general perception that necropsies are not
longer necessary as ante-mortem diagnosis identifies the principal
cause of death and other clinically significant diagnoses
in the vast majority of cases (16). This is not true: the
best method to improve the accuracy of our diagnosis, especially
in the geriatric patients (17), is by obtaining an autopsy
every time one of our patients dies. Autopsy is still considered
as the gold standard for diagnosis (1). Autopsy studies have
provided the source of our knowledge to be applied to future
causes, because detect diagnostic errors, investigate and
discover unsuspected diseases, enhance new therapeutic modalities
and almost always recognize causes of death. Autopsies have
also an important role in monitoring quality among populations
with an increased proportion of geriatric and obese patients
with co-morbidities (18). Despite the acknowledged value of
this post- mortem procedure, hospital autopsy rates have fallen
to only 10 % of deaths and this declining is worldwide (19,
20), especially in the geriatric age (21, 22). However, in
a more recent study it was found that despite a marked decrease
in the total autopsy rate, the geriatric autopsy is rising
Among the causes of this autopsy rate's decline may be costs,
fear of malpractice litigation, and advanced in medical technology
(19). In addition, although autopsy is requested, permission
is refused because of resistance by relatives or by an inadequate
approach by medical staff (23). The most frequent reported
reasons for this resistance are disfigurement of the body,
stress of permitting autopsy, and lack of information about
autopsy (24). When it comes to geriatric patients, another
reason for opposition to the procedure maybe that relatives
consider an autopsy to be futile when conducted on an old
Advances in technology such as ultrasound, computerized tomography,
and radionuclide scans have not reduced the value of the autopsy
(1). The rate of misdiagnosis detected at autopsy (about 40
%) did not improve from 1960-70 to 1980 after the new technologies
became widely used (25). Ermenc (26) reviewed the autopsy
records of 1792 deceased persons and compared the clinical
and post-mortem diagnosis: the diagnoses in total agreement
were only 49,30%.
Such technologies are a double-edged sword and we must judge
carefully the results of every diagnostic procedure: even
if they provide conclusive new information in about 30% of
cases, they also contribute directly to false-positive or
false- negative diagnosis in 6%-9% of cases (27). Particularly
in the old, in whom virtually all organs are damaged and only
patchy structural and functional information is available,
we do not fully understand the complex interactions that are
at play (28). Then, it is essential for us to relate pathologic
diagnostic findings to the history, physical examination,
laboratory results, and other technical data: when considered
alone, diagnostic methods are misleading in high percentage
of cases (27). It has been showed a high percentage of incorrect
diagnosis of the clinicians who were sure about correctness
of their diagnosis; particularly, there was a correlation
between incorrect diagnosis and increasing age (23), although
not confirmed by a further study (29). In those cases in which
hospitalization exceeded one month, there was an increase
in misdiagnosis (23).
More recently, of 53 autopsy series identified, 42 reported
clinically missed diagnosis perhaps because only more difficult
cases are now selected (30).
Another explanation why the misdiagnosis rate has not decreased
over the years can be the pitfalls in correctly diagnosing
diseases in older patients (27). The increased life expectancy
in industrial countries and the resulting higher proportion
of older patients with multiple diseases or atypical cases
may contribute to the unchanged rate of diagnostic errors
The most frequently overlooked treatable diagnoses are pulmonary
emboli (missed in 63 %), myocardial infarctions (missed in
32%), infections (missed in 19%) and neoplasms ( missed in
9%) (25). Pulmonary embolism- common in advanced age- can
be particularly difficult to diagnose because the underlying
thrombosis is diagnosed clinically only 15-20 % of the time,
and it could be difficult to differentiate the pulmonary embolus
from a myocardial infarction (27). Conversely, myocardial
infarctions may be misinterpreted clinically as pulmonary
emboli, especially in the presence of other major underlying
diseases (27). It is interesting to observe that myocardial
infarcts as a cause of death, are more often seen in elderly
women than in men (17). The cause of death significantly differ
in demented and non demented elderly patients: bronchopneumonia
(45.5% in demented versus 28.0% in non-demented), cardiovascular
disease (46.2% in non-demented versus 31.3% in demented) (31).
Unfortunately, however, many clinicians, radiologists, and
others involved in the ante-mortem diagnostic process never
have the opportunity to learn of major missed diagnoses among
patients who died under their care (16).
In summary, the findings at autopsy can help us improve our
diagnostic skills by confirming, clarifying, or correcting
the ante-mortem diagnosis (24). Autopsy remains a valuable
tool to evaluate the diagnostic and therapeutic process, especially
in the geriatric population, because both the atypical presentation
of diseases and limitations in diagnostic scope may lead to
under-diagnosis of potentially treatable disorders (32).
-Let our ignorance of disease in old age serve as a catalyst
for the renaissance of autopsy", says Westendorp (28).
Even centenarians should receive an autopsy; their deaths
should not be merely attributed to old age or senile debility;
the majority of them suffer from chronic co-morbidities even
though they are considered to be healthy (33).
Clinicians would be asked to obtain permission for necropsy
of deaths over and above those cases in which they are particularly
By using autopsy results in teaching situations we can learn
from each other's mistakes (24). Therefore, the goal of autopsy
is not to uncover clinicians mistakes or judge them but rather
to instruct clinicians to learn by their own mistakes. Clinical-pathological
necropsy meetings might be very important to prevent MEs.
However, autopsy also is not infallible: some diseases cannot
be detected by pathologic anatomic examination (e.g. cardiac
arrhythmia) and pathologists may err as clinicians do (26).
MITIGATING MEDICAL ERRORS
Nowadays, Evidence-based Medicine argues that medical decisions
should be based on the firm foundations of high-grade scientific
evidence, rather than on experience or opinion, and this approach
is becoming a cornerstone of patient safety (1). We may battle
against misinterpretation by demanding duplicate independent
We must also avoid overworking our healthcare staff: we cannot
expect a dependable performance from workers who are short
of sleep or working excessively long hours. This sort of problem
is exacerbated in elderly patient because the clinical conditions
of the elderly are complex and impose a great burden of care
(1). Placing a limit on working hours is an obvious way to
reduce ME (34).
Computerized systems have many benefits, including fewer errors
in data recording and communications, the ready availability
of up-to-date information, the sharing of data with colleagues
and nurses, easy access to a patient's clinical history for
follow-up and subsequent hospitalizations. They facilitate
statistical analyses and assessments on the benefit of therapies,
and even reduce public health expenditure by cutting down
on printed matter and time spent on writing and attempting
to read handwritten papers, leaving us more time to listen
to our patients (1). When patients are discharged from hospital,
we may immediately send a complete documentation of their
hospital stay to their general practitioners by e-mail (1).
An appropriate approach to ME might be to acknowledge the
importance of medical training in shaping the physician's
attitude to error. Unfortunately, our medical school graduates
are unable to cope with ME because nothing in their training
prepares them to deal appropriately with the mistakes they
will inevitably make (1). Errors are seldom discussed and
it is assumed that competent doctors do not make any. Medical
students and residents also show little interest in geriatrics,
emphasizing the need for an innovative approach and continuous
exposure to geriatric-focused medical education (35).
Many students react with intense emotion to the idea of making
mistakes in patient care (14), but no psychological support
is available, neither for medical students embarrassed about
approaching the subject of their mistakes, nor for doctors
whose errors have harmed a patient. We need teaching programs
for medical undergraduates that convey a tolerance of ME (1).
The whole undergraduate curriculum could be seen as an effort
to prevent mistakes in clinical practice, with a view to improving
the students' ability to cope with errors (1).
Problem-based learning is a popular teaching method (1);
a database can promote learning, and a course on MEs would
not only help medical students learn to cope with their future
mistakes, but also to reduce their frequency (36). In addition,
medical students must be oriented in the care of elderly patients,
given the demographic realities of medical practice in the
21st century (35).
The Appendix contains a series of recommendations on how
ME rates might be reduced.
Clinical diagnosis is not a "perfect" science like
mathematics, especially when elderly patients are concerned;
diagnosis is more difficult in the elderly, so mistakes are
more common. An excessive work load and understaffing of nurses
in hospitals also seem to have a role in the mistakes made
Since errors are inevitable to some degree, strategies to
improve medical performance have to be developed; accepting
our fallibility and identifying errors are fundamental to
such strategies. When the barriers of shame and punishment
are removed, doctors, nurses, and pharmacists will be able
to improve healthcare, implementing good practices or developing
better ones. To achieve this, healthcare organization managers
(particularly those concerned with geriatrics) need to consider
reducing ME among their top priorities.
In summary, we believe that an appropriate programme on MEs
to students, to remove the barriers of shame and punishment,
to learn from others' errors and to report ours by detecting
autopsies, to accept our fallibility, are the basis for coping
with our mistakes and for reducing them.
A reflection for all us
We may think on Leape et al.'s (37) words every time we are
at the bedside of a patient: "Errors are not diseases:
They are symptoms of diseases". The diseases are the
inadequate systems we have create in our health care systems.
Like pain or fever, it is only when we investigate and discover
the causes that we will succeed in eradicating the symptom.
- Use modern technologies, evidence-based medicine, and
problem-based learning in medical student education
- Teach students to accept responsibility for their mistakes
and motivate them to care for elderly patients
- Develop systems for preventing medical errors in hospitals
- Create a national database of errors that can be shared
and updated, from which to draw recommendations on the security
of the elderly patient and the quality of the healthcare service
- Avoid the use of handwritten prescriptions and paper
medical records by using computerized systems
- Communicate with colleagues of other specialties to
make joint decisions on therapies, thus avoiding drug interactions,
which are very common in elderly patients
- Establish a good link among doctors, nurses and pharmacists,
as elderly patients often have co-morbidities
- Establish good communications with relatives and patients,
and spend enough time with them to adequately assess symptoms
and signs, because this is often very difficult to do in geriatrics
- Obtain a detailed history and perform an accurate physical
examination, not "trusting" entirely on laboratory
and instrumental test findings
- Be aware of the limitations of the diagnostic methods
- Have duplicate independent readings of X-rays, ECGs,
angiograms, and histological specimens
- Use error reporting to learn from past errors
- Increase the necropsy rate in geriatrics (including
centenarians) to produce a higher rate of confirmation of
- Improve the approach to obtaining consent to autopsy
from relatives, even if they resist the idea because the patient
- Create voluntary (non-punishing) error reporting programs
(with a view to obtaining reliable data on medical errors)
- Create medical codes for errors
- Involve leaders in the medical profession and healthcare
organizations by means of open discussions
- Accept the fact that we are human so we are not infallible
(a dose of humility is needed), and that we cannot work "miracles"
in the geriatric age group.
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Prof. Eminè Meral Inelmen
Clinica Geriatrica-Ospedale Giustinianeo (2°piano)
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