The Big Risk We Don’t Talk About Enough: Medical Errors

When you walk into your doctor’s office or a hospital, you probably don’t immediately think about medical errors. Yet for those of us who’ve worked inside the healthcare system, we know they happen every day. They usually are unintentional, but even a minor mistake can lead to serious harm or even death.

This isn’t new. I first wrote this article as a research paper three years ago, in 2022, and the data at that time was staggering. Sadly, the situation hasn’t improved, and with the challenges to healthcare resulting from the implementation of The Big Beautiful Bill that was recently put into law, medical errors are likely to occur more frequently due to staffing shortages and cutbacks in services.

Medical errors remain one of the leading, but least acknowledged, causes of death in the U.S.—and unlike heart disease or cancer, they don’t even appear on the CDC’s top causes of death list. 

So, what are medical errors? The definitions vary, but generally they include:

• Errors of execution: a planned action that isn’t completed as intended.
• Errors of planning: the use of the wrong plan to achieve an aim.
• Deviations from the care process, which may or may not result in harm (5).

The most common hospital-based errors include adverse drug events, hospital-acquired infections, surgical complications, ventilator-associated pneumonia, pressure ulcers, falls, and wrong-site surgeries (1). Outside the hospital, misdiagnoses and delayed diagnoses, especially in emergency settings, are major issues often involving strokes, heart attacks, sepsis, and certain cancers (7).

Who Makes Errors—and Why?

It’s tempting to think of errors as individual failings, but the reality is more complex. Physicians, nurses, pharmacists, therapists, and techs are all human and all vulnerable to mistakes, but most errors are systemic. Communication breakdowns, staffing shortages, documentation overload, and fragmented systems create conditions that foster errors (7).

For example, the Affordable Care Act (ACA) pulled nurses away from the bedside with documentation mandates. Instead of caring directly for patients, nurses have spent more time entering data into electronic systems—creating fewer opportunities for oversights and more opportunities for missed care. Combine that with an aging workforce, post-COVID burnout, and an overall shortage of clinicians, and the margin for safety has only gotten thinner.

The Numbers Behind the Crisis: The statistics are sobering:

• In 1999, the Institute of Medicine estimated up to 98,000 deaths per year due to medical error (8).
• A 2004 analysis put the number closer to 195,000 deaths per year among Medicare patients (6).
• By 2008, the Office of Inspector General reported 180,000 deaths per year in Medicare inpatients alone (4).
• More recent data suggests the true number may be closer to 376,000 deaths annually (3).

Despite this, medical error isn’t officially tracked the way other causes of death are. That lack of standardized reporting allows the problem to remain largely hidden.

What Can Be Done?

Hospitals have introduced safety protocols like “Time Outs” before surgeries and better fall-prevention strategies, but these efforts haven’t eliminated the errors. Until there is a national push for transparency and accountability, the responsibility often falls on patients and families to stay vigilant.

Here are practical steps you can take:

1. Keep a hospital binder with essential documents: medical power of attorney, living will, updated medication list, allergies, recent labs and imaging reports, and emergency contacts. Bring it to every appointment or hospital visit.
2. Have a second set of eyes and ears present. A trusted family member, friend, or advocate can help track care, clarify instructions, and catch inconsistencies. Come prepared with a notebook!
3. Ask questions without hesitation. If something doesn’t sound right, or if an order seems inconsistent, speak up.
4. Track medications: Verify what you’re being given, the dose, and why. Errors in prescribing or administering drugs are among the most common and preventable.
5. Keep your own records. Don’t rely solely on portals or hospital systems to communicate between providers.

How an Independent RN Patient Advocate Can Make a Difference

An Independent RN Patient Advocate combines clinical expertise with undivided loyalty to the patient—not the hospital, not the insurance company. An advocate can:

• Review records and catch discrepancies before they cause harm.
• Coordinate communication among providers who may not share information.
• Educate patients and families on what test results, diagnoses, and treatment plans really mean.
  Stand beside you (or virtually with you) to make sure your care is safe, accurate, and aligned with your wishes in real time.
• Communicate with your care team and ensure that your goals are kept at the forefront of each decision.

Errors are an unfortunate reality of modern healthcare, but they don’t have to define your experience. By preparing ahead and enlisting the right support, you can dramatically reduce the risks for yourself and your loved ones. Retaining an Independent RN Patient Advocate before being hospitalized can optimize your safety. Contact CompassHealthRN@outlook.com for more information about our services or book a free consultation so we can connect by visiting our website www.compasshealthadvocacy.com.

References

1. Carver, N., Gupta, V., & Hipskind, J. E. (2022, July 4). Medical error — stat pearls — NCBI bookshelf. National Library of Medicine. Retrieved November 20, 2022, from www.ncbi.nlm.nih.gov/books/NBK430763/

2. Centers for Disease Control and Prevention. (2022, September 6). FASTSTATS — leading causes of death. Centers for Disease Control and Prevention. Retrieved November 20, 2022, from www.cdc.gov/nchs/fastats/leading-causes-of-death.htm

3. Classen D, Resar R, Griffin F, et al. Global “trigger tool” shows that adverse events in hospitals may be ten times greater than previously measured. Health Aff 2011; 30:581-9doi:10.1377/hlthaff.2011.0190.

4. Department of Health and Human Services. Adverse events in hospitals: national incidence among Medicare beneficiaries. 2010. oig.hhs.gov/oei/reports/oei-06-09-00090.pdf.

5. Grober, E. D., & Bohnen, J. M. A. (2005, February). Defining medical error. Canadian journal of surgery. Journal canadien de chirurgie. Retrieved November 20, 2022, from www.ncbi.nlm.nih.gov/pmc/articles/PMC3211566/

6. HealthGrades quality study: patient safety in American hospitals. 2004. www.providersedge.com/ehdocs/ehr_articles/Patient_Safety_in_American_Hospitals-2004.pdf.

7. Institute of Medicine (US) Committee on Quality of Health Care in America; Kohn LT, Corrigan JM, Donaldson MS, editors. To Err is Human: Building a Safer Health System. Washington (DC): National Academies Press (US); 2000. 3, Why Do Errors Happen? Available from: www.ncbi.nlm.nih.gov/books/NBK225171/.

8. Kohn LT, Corrigan JM, Donaldson MS. To err is human: building a safer health system. National Academies Press, 1999.

9. Makary M.D., M.P.H., M., & Daniel, M. (2016, May 3). Study suggests medical errors are now the third leading cause of death in the U.S. — 05/03/2016. Johns Hopkins Medicine, based in Baltimore, Maryland. Retrieved November 20, 2022, from www.hopkinsmedicine.org/news/media/releases/study_suggests_medical_errors_now_third_leading_cause_of_death_in_the_us