Improving Patient Safety in Diabetes Care: The Importance of Reducing Medical Errors

Abstract

In 1999, at the President’s Poster Session of the American Diabetes Association’s 59th Annual Meeting and Scientific Sessions, we presented our findings on the importance of medical errors in diabetes care.1 We found that errors in diabetes care were a common cause of significant morbidity and complications and not uncommonly resulted in disability and even death. The data were straightforward and well accepted, although, privately, many physicians commented to us that the absolute number of errors in care resulting in poor clinical outcomes was even higher than we had reported. The general problem facing health care providers is now generally well accepted by the public. The Institute of Medicine report2 catapulted the issue of medical errors onto the front pages of magazines and newspapers throughout the United States. The public believes that our system can and should be improved. But how? Earlier this year, at the American Association of Clinical Endocrinology Annual Scientific Sessions, I presented a workshop titled “Sleuthing Strategies: Improving Patient Safety by Reducing Medical Errors.”3 Our earlier work4 had made it clear to us that the real challenge is not to document how bad it has been, but instead to focus on how to help those who are actually providing care to patients. This task is much more difficult but much more important and likely to be what we will need to improve care. Among the many misconceptions that people have about medical errors, particularly in diabetes care, is the mistaken belief that there is always someone to be held accountable for the error and that the focus should be disciplining and ultimately removing the “bad apple” from the system so that it can function properly.5 In truth, most of the important medical errors are multifactorial in nature and are the result …