Medical errors are a serious public health problem and the third leading cause of death in the United States. Personal and institutional financial burdens of medical errors are estimated to be $20 billion annually. Despite the significant toll on society, uncovering a viable solution to preventing healthcare errors remains a challenge. Establishing a culture of safety rather than blame and punishment is crucial to developing system-wide protocols for improving safety measures on how to prevent medical errors in healthcare. Solutions to this threat to patient safety require the participation of every individual on the healthcare team, from nurses and physicians to organizational leaders.
Recommended course: Medical Errors and the United States Healthcare System
Preventing medical errors in healthcare: Defining medical errors
Medical errors are errors that cause harm to the patient from either:
- Error of omission defined as a failure to perform an action resulting in patient harm.
- Error of commission defined as performing the wrong action resulting in patient harm.
Identifying errors requires the presence of two critical parts: harm to the patient and whether that harm was preventable. To develop patient safety protocols, healthcare professionals should have knowledge of general terms and their meanings.
Common terminology
- Active errors. Errors result when humans interface with a complex system such as healthcare (e.g., nurses and physicians).
- Latent errors. Errors resulting from the faulty installation or maintenance of equipment, ineffective organizational structure, or errors inherent to a system or process design.
- Adverse event. Injuries to a patient resulting from a medical or surgical error rather than an underlying medical condition.
- Near-miss. An event that could have resulted in harm, but chance or intervention prevented it from happening.
- Negligence. Deviation from the standard of care expected from a qualified healthcare professional in a similar situation.
- Sentinel event. Any event causing serious physical or psychological injury or death and requires immediate action to identify the cause and develop a preventative response.
- Never event. Events that should never have happened, such as a wrong-sided surgery.
How to prevent medical errors in healthcare: A root cause analysis
A root cause analysis (RCA) is a retrospective review identifying the causative factors that lead to an error event. The RCA helps modify or change the system to prevent future similar occurrences. It helps identify latent errors, reasons why the system failed, and factors that contributed to the conditions in which the error occurred.
An RCA uses a multidisciplinary team to investigate any system-based error. However, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requires the performance of an RCA to evaluate all sentinel events and report them to their organization. The RCA team focuses primarily on systems and processes, not the actions of an individual. The team identifies changes in systems and processes to improve performance and reduce the incidence of sentinel events.
How to conduct a root cause analysis
Once an event is identified, a multidisciplinary team of individuals from different disciplines work independently to complete the same objective, defining causal statements that clearly show a cause-and-effect relationship and developing corrective solutions. The RCA consists of five individual steps.
Step 1: Data collection
This step works to develop a timeline of all events immediately preceding and following the error. This allows the team to identify factors that may have contributed to the error and see areas of improvement within the system.
Step 2: Assessment
The data is analyzed to identify problems, determine their significance, and identify the immediate conditions that proceeded and followed the problem. Focusing on one visible causative factor should be avoided during this step. Once the assessment is complete, a cause-and-effect diagram describes the sequence of events leading to the latent error.
Step 3: Identify root causes
After identifying the reason the causes that led to the error were present, the team must work to understand the fundamental or root causes for which, if corrected, prevention of recurrence will be achieved.
Step 4: Generate solutions
The development of a root-cause summary table occurs during this stage of the RCA. This table lists all causal factors, identifies the root causes, and provides recommendations for remedying the root causes. This step consists of developing recommendations and implementation guidelines to prevent the recurrence of the error.
Step 5: Explanation and dissemination of results
The final step involves informing and explaining the results of the RCA to management and the personnel involved in the error. It also demands the performance of a follow-up to determine if the corrective action has been effective in resolving the problem.
Factors contributing to medical errors
Medical errors are pervasive throughout healthcare. Multiple contributing factors often feed into a single event. These factors fall into many different categories.
- System and organizational factors. These factors include staffing shortages, inadequate training, and poor supervision. Insufficient policies and procedures governing high-risk behaviors are additional factors leading to medical errors.
- Technological factors. Misuse of technology, technical failures of medical equipment, and issues pertaining to electronic medical records and medication administration systems are commonly identified technology-based factors.
- Human factors and behaviors. These factors include breakdowns in communication, clinician burnout, fatigue, implicit and cognitive biases, and failure to report errors.
How to prevent medical errors in healthcare: Strategies and tactics
Reducing the number of medical errors can have a significant impact on the quality and safety of medical care within the United States. Developing and implementing strategies are essential steps in identifying and preventing common medical errors.
Making patient and staff safety a priority is one such strategy utilized by many health systems to reduce medical errors. This involves frequent educational programs, systematic reporting systems, and quality control measures to ensure policies and procedures are effective.
Developing a checklist can reduce the risk of errors, and emphasizing procedures geared at addressing the most observed surgical errors is effective in preventing error events. For example, performing a time-out prior to incision or induction of anesthesia to correctly identify the patient, procedure, and site can drastically reduce the risk of wrong-site surgeries.
When addressing medication errors, commonly used strategies include the use of barcodes, standardized units of measure, enforcing double and triple checks, and involving pharmacists in clinical care activities.
Finally, developing a culture of communication can prevent errors. It also contributes to changes in the administration of medical care that minimize mistakes. A collaborative, respectful environment within healthcare organizations can encourage good clinical communication. Acknowledging that mistakes happen and incorporating communication strategies into staff training go a long way in protecting patients from preventable harm.
