**2. Actions and omissions which are associated with errors in healthcare**

In an attempt to create a glossary of terms regarding patient safety, the EU Patient Safety and Quality of Care Expert Group accepted Reason's definition of error, which identifies two types of errors (**Figure 1**) [6].

According to Reason [6], errors are separated into "active" and "latent" errors. In "latent errors," effects occur later, and they are attributed to poor planning, increased workload, poor organization, and inadequate training of the personnel; in "active errors," effects are direct and may be detected instantly upon occurrence [6]. The terms "active failures" and "latent conditions" or "latent failures," the definitions of which are presented subsequently, are also frequently used:

**Figure 1.** Types of errors by Reason. Source: Reason [6].

**i.** "Active failures": direct failures, unsafe acts carried out by people in direct contact with the patient or the system [7]. The effects become apparent almost instantly or at least within a few hours. These errors are often referred to as "errors on a knife-edge" [8]. It is true that people being on a "knife-edge" make errors, but this is only one part of the truth—and not even the most crucial.

services provided grows constantly, as mortality and morbidity caused by medical errors demonstrate increasing trends throughout the ages, particularly in countries with deficient social and scientific maturity. In developed countries, one in 10 patients experiences adverse events during hospitalization, according to World Health Organization (WHO). These events could have been predicted and prevented. Moreover, the risk in developing countries is 20 times higher, compared to developed countries [3]. Two categories of errors, which are

"Communication errors" between healthcare professionals could negatively have an effect on patient safety throughout routine care and even more so during emergency care and in code situations. Training and recent procedures have been established to decrease communication

"Wrong-site procedures" are a high-impact, low-frequency "never event" that exists all through procedural specialties. Effects of "Wrong-site procedures" are significant, starting with the psychological and physical harm to the patient. Moreover, the affected patient's loved ones are likewise highly likely to suffer emotional effects of having been, not in a direct

In an attempt to create a glossary of terms regarding patient safety, the EU Patient Safety and Quality of Care Expert Group accepted Reason's definition of error, which identifies two

According to Reason [6], errors are separated into "active" and "latent" errors. In "latent errors," effects occur later, and they are attributed to poor planning, increased workload, poor organization, and inadequate training of the personnel; in "active errors," effects are direct and may be detected instantly upon occurrence [6]. The terms "active failures" and "latent conditions" or "latent failures," the definitions of which are presented subsequently, are also frequently used:

**2. Actions and omissions which are associated with errors in** 

mentioned subsequently, are the most reported the latest years.

manner, unprotected to a wrong-site event [5].

**Figure 1.** Types of errors by Reason. Source: Reason [6].

errors [4].

14 Vignettes in Patient Safety - Volume 3

**healthcare**

types of errors (**Figure 1**) [6].

**ii.** "Latent conditions or latent failures": latent conditions, inevitable inner pathogenic "micro-organisms" of the system that lead to errors. They arise from decisions taken at the strategic level and, thus, by the top management. Consequently, they are associated with the organization's structure, design, planning, training, forecasting, budget, resource allocation, etc. Latent conditions are manifested in two ways. The first way is by influencing working conditions so that the employees are prone to errors (e.g., time pressure, understaffing, lack/shortage of equipment, etc.) and the other way is by creating gaps in various organizational "defense levels" (e.g., unreliable alarm systems, design and construction defects, etc.). As the term suggests, latent conditions may remain ineffective inside the system for many years, and when combined with "direct failures," it may lead to the occurrence of several and different adverse events [6].

The difference between "direct" and "latent failures" lies, on the one hand, on timing, and, on the other hand, on the level of the system they will manifest. In "direct failures," people's actions have immediate effects, whereas in indirect failures, the effects may not be obvious or appear much later and only provided when they are combined with other direct failures. As a result, professionals being on a "knife-edge" are easier to blame. This may also be attributed to the fact that the detection of the root causes is rather hard and is often related to the organizational level. "Direct failures" usually occur to those who are directly related to the patient, whereas indirect failures are mostly associated with the organizational and administrative level. "Indirect failures" may be "transferred" along organizational and departmental pathways in the workplace (e.g., in an operation room (OR), etc.), locally generating the conditions that favor the occurrence of errors and misconducts.

Reason [7] compared the "individual's approach" to the effort made by an individual trying to kill a mosquito that bit them and the "system approach" to the effort to drain the swamp wherein mosquitoes procreate. "Individual approach" focuses on the errors of the employees, for example, by blaming them for carelessness. It is, however, a fact that errors are not realized only by incompetent but also by very competent healthcare professionals, and they are often the most competent professionals, who make the worst errors. "System approach" focuses on the conditions under which the employees perform their duties. This approach is mainly adopted by organizations that require highly reliable services (e.g., aviation), and it is considered the most appropriate by the scientists who have dealt in depth with errors in the healthcare sector [7, 9].

Based on previously mentioned definitions of errors, Reason [6, 7], focuses on the process design and implementation and not on the outcome and the consequences, thereof taking into consideration the fact that those psychological, physical, and technical failures abet to the conduction of an error. He, however, overlooks the errors caused by omissions (error of omission) [6, 7].

In contrast, Leape [10] refers to errors attributed to actions or omissions but overlooks the actions based on design errors, unless they lead to adverse effects. Reason's and Leape's definitions are subjected to several limitations. Although an action may be mistaken or the plan for the accomplishment of the desired effect may not be appropriate, errors or omissions must not be always blamed for adverse events in the healthcare sector, since there are other factors that contribute to them, such as an unexpected allergic response to a new medication treatment.

**3. Adverse events in healthcare**

freedom from random harm [11].

"noxious episode" for the first time.

drug events, etc.) [29].

safety dictates an outcome-based approach of medical error.

patient's disability, prolonged hospitalization, or even death.

A previous literature review includes research on patient safety issues that mainly focus on adverse outcomes from the practice of medicine, adopting definitions of medical errors and related terms based on the adverse outcomes of medical practice [20–24]. This could be explained by the basic medical principle of Hippocrates, which is summarized in three words: "Primum non nocere" or "First, do no harm" [10, 25]. Moreover, the definition of patient

Defining Adverse Events and Determinants of Medical Errors in Healthcare

http://dx.doi.org/10.5772/intechopen.75616

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"Patients' safety" is defined as avoidance, prevention, and improvement of negative effects or injuries caused to patients during healthcare provision [26]. IOM defines "patient's safety" as

In his study "Hazards of Hospitalization," Schimmel [27] argued that the evaluation of undesirable effects resulting from healthcare provision, as well as the registration of their frequency, is necessary regardless of the severity of the effects. It is also paramount that an overall risk assessment is realized, regarding the patients' exposure to polypharmacy and complex procedures during healthcare provision. Within this context, he introduces the term

"Noxious episodes" are all the unpleasant events, the complications, and the misfortunes caused by acceptable diagnostic and therapeutic measures executed in the healthcare unit [27].

The term "potentially compensatable event" was introduced for the first time in 1977 in the study titled "The California Medical Insurance Feasibility Study," defining it as an event that occurs during healthcare provision and leads to disability or prolonged hospitalization [28].

Four major researches regarding errors in the healthcare sector were published in the 1990s, emphasizing the term "adverse event." According to "Harvard Medical Practice Study" [20, 21], "The Utah and Colorado Medical Practice Study" [22], "The Quality in Australian Health Study" [23, 24], and the study of IOM in US "To Err is Human: Building a Safer Health System" [11], an "adverse event" is defined as a localized damage or complication caused to patients by medical care that does not result from patient's impending disease and leads to

"An adverse or undesirable event" refers to an outcome of a process, whereas an error characterizes an action itself. This means that an error may cause an adverse event or not, either because this action caused no harmful effects and the patient did not experience any symptoms or because it was detected on time and was prevented. An error constitutes a necessary but not sufficient cause of an "adverse event." This is explained by the fact that "adverse events" do not always result from errors or omissions; they may also arise from appropriate actions with "adverse effects" (complications) that were either unknown at the time the action was taken or they were known and expected but could not be prevented (e.g., adverse

Leape [10] classifies "adverse events" into three categories as shown in **Figure 2**.

An equivalent definition of error, similar to the one provided by Reason [6], is the definition by the Institute of Medicine (IOM)<sup>1</sup> in the United States in 1999, in a published report, regarding errors in the healthcare sector. Therewith, a "medical error" is defined as the failure to complete a planned action or the use of ineffective planning for the accomplishment of an objective [11].

In a report published in 2000 regarding medical errors and patients' safety, Quality Interagency Coordination Task Force (QuIC) in USA attempts a conceptual clarification of error in the healthcare sector expanding the definition that was provided by the IOM the previous year. According to this definition, "error" is defined as the failure to complete a planned action as expected or as the use of incorrect/poor planning to achieve an objective. According to the same report, "medical errors" may also refer to processes, practices, and equipment [12].

In order to understand the concept of error in the healthcare sector more accurately this time, Reason [13] defined error as the variations in the provision of healthcare that may cause harm to the patient. Other definitions concerning medical errors, which were published recently, are presented in **Table 1**.


**Table 1.** Additional definitions of medical errors.

<sup>1</sup> Institute of Medicine (IOM) has been renamed to National Academy of Medicine (NAM).
