Most of us think of medical errors as something a provider did to a patient that caused harm; however, a common type of medical error is the error of omission. Errors of omission happen when something should have been done for the patient to reduce the risk of harm, and it was not done.
In a study published in the New England Journal of Medicine (August 2011), three physicians tell the story of a 53-year-old woman who nearly died of pneumococcal sepsis. She had had a splenectomy after an automobile accident 10 years earlier, but had not received the evidence-based vaccinations recommended by the Centers for Disease Control. This was vaccination against pneumococcal infection at 5-year intervals. The study authors found that not receiving recommended vaccines was a common problem for splenectomy patients within their health delivery system, a system flaw which has implications for many other kinds of patients. While they offer a few potential solutions to prevent these common medical errors, they left out the important one: better engagement of patients in their care. The authors note that we need a health delivery system that makes it easy to do the right thing and difficult to do the wrong thing. How such a system is created is unclear.
As a patient you cannot ask too many questions about your care and you must review your medical records for omissions and mistakes. You only have one life. You do not want to follow the pathway of the 53-year-old woman who needlessly walked near death because she had not been given evidence-based vaccinations. Informing yourself as a patient can help you and your loved ones avoid harm.
Read John’s patient safety October 2011 newsletter here. Visit his website, Patient Safety America, here.