Analysis of 10 years of medical errors investigated by the Poznan University Forensic Medicine Department

Introduction

Medical errors are extremely dangerous for patients’ lives and health and generate severe costs. It was calculated that medical mistakes cause around 100,000 deaths per year in the USA; furthermore, they require payment of over 50 billion dollars.¹ Emergency medicine seems to be one of the most sensitive error fields in entire medicine. Some of the factors that increase the risk of mistake are high levels of diagnostic uncertainty, high decision density, high cognitive load, high levels of activity, the inexperience of some physicians and nurses, interruptions and distractions, uneven and abbreviated care, limited time windows and shift work or shift change.²

At the turn of 2005 and 2006, the polish emergency medical service underwent some profound changes, the most important of which was the division of emergency medical service teams (EMS) into two types: basic P-type ambulance and specialized S-type ambulance. The P-type ambulance includes only paramedics or nurses; the S-type consists of paramedics or nurses and a physician.³ At the same time, Hospital Emergency Departments (HEDs) were also created. HEDs became a central element of the medical rescue system in Poland. In the beginning, the plan of the reform assumed that only emergency medicine physicians would work in specialist EMS; however, due to their low availability, the list of physicians allowed to work in medical emergency teams has been broadened. In addition to emergency medicine physicians, an anesthesiologist, an internist, a cardiologist, a surgeon, a pediatrician, a pediatric surgeon, and then a physician with 3,000 hours of experience in the HEDs or the EMS and a neurologist could work in the specialist EMS.⁴ Due to the growing deficit of physicians in Poland, work is underway to completely liquidate S-type ambulances and introduce an equivalent of the Rendez Vouz system with a physician commuting to the basic team on call, similar to the solutions existing in the UK. However, the proposed changes arouse much controversy in the Polish emergency medicine community, as a complete lack of a physician in the Emergency Medical Service is perceived as a danger to the patient.

The authors decided to look at the emergency medical services system’s functioning in light of expert opinions of the Department of Forensic Medicine in Poznań from 2005-2015 in cases of medical errors committed in emergency medicine. This retrospective study aimed to determine which elements of the medical rescue system in Poland (in its form with both types of EMS teams) errors most often occurred, what kind of errors they were, and how often they resulted in a patient’s death. In addition, the study aimed to determine which type of emergency medical team (P or S) was more likely to make medical errors, including errors ending in a patient’s death.

The source of the analyzed research material was the archives of the Department of Forensic Medicine at the Medical University of Karol Marcinkowski in Poznań (ZMS). The collection includes all opinions issued by ZMS, broken down by year. Each document is assigned a unique number: the serial number of materials received by ZMS and the year in which it took place. It should be borne in mind that the described register only lists cases that had a decision issued by police units, prosecutor’s offices, courts, and other state services. The analyzed material included matters concerning all Polish units, except for the Greater Poland Voivodeship. Therefore, it covers about 90% of the population and 80% of the country. The members of the evaluation teams were employees of ZMS in Poznań and doctors cooperating with ZMS, most of whom came from the group of independent scientists of the Medical University of K. Marcinkowski in Poznań.

To the authors’ knowledge, this is the first such study on medical errors in the Polish emergency medicine system after the 2005 reform. The authors hope that this paper will be a valuable voice in the ongoing discussion in Poland on the planned changes in the emergency medical services system and will also provide interesting information for comparison for researchers into the problem of errors in emergency medicine from other countries, which, despite its great importance, has not been reflected in the scientific literature in recent years.

Methods

The authors reviewed archival data containing anonymized forensic medical opinions. To work on such material by the rules applicable to the authors of scientific papers, it is not required to obtain the consent of the bioethical commission or other entities. This article analyzed 147 opinions issued by the Forensic Medicine Department at Poznań University of Medical Sciences in 2005-2015 that concerned medical errors in emergency medicine commissioned by judicial authorities from all over Poland. The study excluded opinions on the areas covered by the jurisdiction of the Appellate Prosecutor’s Office in Poznań and the District Prosecutor’s Office in Ostrów Wlkp., which is about 85% of the country’s territory.

Analysis of medical mistakes should include scale valuation, identify causes of errors and allow for the evaluation of the effectiveness of actions taken to eliminate them.⁵ All of the above factors make analysis hard to be done correctly. Furthermore, it seems extremely difficult since there is no universal definition and classification of medical errors,⁶ and there is no organized system for collecting data concerning medical errors in Poland.

For this work, a medical error shall be understood as “a violation by a doctor or another employee of the medical rescue system (who is aware of the fact that a medical act is taken) of the rules of professional conduct towards legal goods in the form of human life and health, which, based on the law, constitutes a basis for determining a breach of duty of care”.⁷ The authors used two typologies of medical errors in their analysis. The first one is based on the type of committed error. This typology is used in Polish jurisprudence and was chosen by the authors because the research material consisted of opinions issued by the Polish judiciary. It includes the following categories of medical errors: diagnostic, therapeutic, and organizational.⁸ Diagnostic error is medical malpractice involving misdiagnosis, failure to diagnose, and the resulting consequences.⁷ A therapeutic error includes the conduct of faulty therapy despite a correctly made diagnosis.⁸ An organizational error refers not so much to a flawed treatment process as to the bad organization of work.⁹ It includes all types of incorrect decisions of managers (chiefs, clinic managers, heads of operational teams) or equipment malfunctions.¹⁰

The second division used in this study includes errors classified by their effect on a patient’s life and health (Table 1). Critical errors pose a direct threat to the patient’s health and vitality. Moderate errors can be detected during the performance of medical activities but do not pose an immediate threat to the patient’s life and health. Subtle errors do not pose a danger to the patient and are possible to be discovered only in a post-factum analysis. The basis for this division was the AHQR Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation,¹¹ which distinguishes nine categories of medication errors due to possible effects on the patient. Due to the small sample size and the need for statistical analysis, the researchers decided to reduce the nine categories to three.

Due to the lack of a medical error reporting system in Poland, the only available source of information regarding them is forensic medical opinions commissioned by prosecutor’s offices and criminal and civil courts. According to Polish law, medical errors are issued by forensic medicine specialists, who team up with emergency medicine specialists to determine if a mistake was committed and what were, if any, the health consequences for the patient. In some cases, specialists determine whether a patient’s death can be linked to the error.¹²

The study analyzed all (n=147) opinions issued by the Forensic Medicine Department at Poznań University of Medical Sciences from 2005-2015 that concerned medical errors in emergency medicine commissioned by judicial authorities from all over Poland. The beginning of the studied period was determined by the start of the emergency medical system reform. The year 2015 was when all the analyzed cases were definitively closed. The authors could not use opinions from 2016 to 2021 for research as some of them were still pending. Hence, new evidence may still appear, which may change the experts’ opinion; however, it is not within the scope of this study. During the analysis, the descriptive data contained in the medico-legal opinions were transformed into numerical data and collected in a spreadsheet. Each case was assigned a type of error at subsequent stages of medical assistance; if such an error occurred, and then its severity was determined, and the statistical number of the disease was assigned according to ICD-10.

The Statistica 10.0 PL was used for statistical analysis. The analyzed variables were represented on qualitative scales and described with the number of individual categories (n) and the corresponding percentage (%). Correlation analysis was performed using the chi-square test of independence. The significance level was assumed to be α=0.05. The results were statistically significant when the calculated test probability p met the inequality p<0.05.

Results

Out of 147 analyzed cases, 47 (32%) included patients that visited HED independently. In 100 cases (68%), an emergency medical service team was sent to the patients. In 40% of cases (n=40), it was the basic team, and in 60% (n=60), it was a specialist team. Cardiovascular disease and trauma were the most common reasons that made patients require emergency medical care (see Table 2).

Out of 147 analyzed cases, experts found various medical errors committed in 103 patients (70.1%). The analysis did not show a connection between the reason for requiring emergency help and the occurring medical error.

Out of 103 cases where a medical error was committed, in 74 cases, the error resulted in the patient’s death (71.8%). Statistical analysis showed that after the occurrence of medical error, the risk of patients’ death increased twice (RR=2,105, see Table 3).

These errors were made in every component of the system, in some cases all at the same time. Still, the most significant number (69. 9%) were made in emergency rooms, which can be inferred from the fact that almost all patients included in the analysis ended up in hospital emergency departments (see Table 4).

By distinguishing different types of medical errors (see Figure 1), it can be seen that most of the diagnostic and therapeutic errors were committed at HEDs. The probable reason is that this is where most of the activities related to the diagnosis and treatment of patients were performed. In the case of HEDs, it is worth noting that, unlike other system elements, no organizational errors were found in them. Therefore, in light of the research material, this is the best-organized part of the system. Another exciting result visible in Figure 1 is the low percentage of diagnostic errors at the level of system dispatchers. This may prove that they correctly recognize the problems faced by patients and choose the right solutions. On the other hand, the highest percentage of organizational errors concerned cases in which the error “extended” to several system components simultaneously, which may indicate imperfect cooperation between system components.

Figure 1. The frequency of organizational, diagnostic, and therapeutic errors in various elements of the emergency medical system.

Analysis of the location of errors distinguished based on their effects on the patient’s condition (see Figure 2) shows that in the case of critical errors, almost half of them (49.4%) were committed at the HEDs. Nearly a quarter of this error concerned several system elements simultaneously (24.10%), and EMS committed 22.9% of them.

Figure 2. The frequency of committing critical, moderate, and subtle errors in various elements of the emergency medical system.

The errors committed by the Emergency Medical Service teams (EMS teams) were analyzed separately. In 100 analyzed cases in which the EMS Team was involved, there were 74 in which the experts found an error. Statistical analysis showed that in P-type ambulances (without a physician), significantly more mistakes were made than in S-type ambulances (with a physician on board) (see Table 5).

The analysis of the frequency of making a mistake resulting in the patient’s death (critical errors) showed that it’s a highly similar situation to the one described above. In the case of the P-type ambulance, the patient’s chance of death was almost 1.5 times higher than in the case of the team with a physician (see Table 6).

Discussion

This study shows that committing a medical error within the emergency medical system more than doubled the risk of a patient’s death. The awareness of the tragic consequences of a possible mistake or neglect should be as every day as possible among system employees, especially in a situation where, as shown by other studies, nearly 40% of deaths caused by injuries were the result of avoidable errors.¹³

According to the authors, the results of the analyses indicating the HED as the place where the most significant number of errors of all types are committed are not surprising. HEDs, as a critical point of the medical rescue system in Poland, support almost all patients requiring emergency medical assistance, so the risk of a medical error in this system element is the most likely. What drew the authors’ attention is that no organizational errors were noted at the HEDs that would occur only within the department. In comparison, the research from South Korea concerning the case of the analysis of errors in the treatment of injuries states that more than 50% of organizational mistakes were made in emergency departments. This may indicate an excellent organization of emergency medical services in the Polish emergency medicine system.¹³

In our work, we used Poland’s medical error assessment system. It differs from the modern classification systems used in other countries, such as the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) and those proposed by researchers. It should be mentioned that Bhasale et al.¹⁴ based its scale on self-reporting, which there is no point in the current legal system in Poland. Likewise, Holden et al.¹⁵ analyzed the deaths of patients only in formal terms. The above examples allow authors to assume that the proposed medical and judicial point of view will also apply to healthcare systems similar to Polish, such as the Czech, Slovak and Russian systems.

The results concerning errors made by the EMS teams seem much more interesting. They show that errors in the P-type ambulances, i.e., without a doctor in the rescue team, occurred much more often, including those resulting in the patient’s death. It can therefore be concluded that the higher level of preparation of the emergency medical team members translates into a higher level of patient safety. However, some scientific reports indicate that this does not have to be the case. Bayley et al.¹⁶ suggest in their studies that more formally qualified rescue teams committed more errors in simulating cardiac arrest than less qualified teams. However, these studies concerned only paramedics, so they are not comparable with our findings, which may constitute a voice in the current discussion in Poland on the idea of withdrawing doctors from emergency medical teams and entrusting ambulance services only to paramedics and nurses.

Conclusions

The main conclusions of our research are:

Committing a medical error in emergency medical services more than doubled the risk of a patient’s death in the studied period. Hospital emergency departments seem to be the best-organized part of the Polish emergency medical system in the studied period. The number of medical errors made by emergency medical teams with a doctor on board was significantly lower than the number of mistakes made by groups without a doctor. There is a need to build a system for collecting data on medical errors in emergency medical services and their analysis, which will allow for their elimination in the future. There is a need for future studies on medical errors in Polish emergency medical services to monitor their functioning, especially after the proposed elimination of the S-type EMS teams. It is vital to check both the cost-effectiveness of the Rendez–Vouz system and its safety for the patients if and when it is introduced.