Communication Accurate communication is vital for diagnosing, treating, dispensing and administering medications, maintaining patient safety, following policies and procedures, and ensuring treatment instructions are carefully followed. Communication errors can be verbal or written and occur in every part of the care delivery process. Breakdowns in communication are one of the leading causes of medical errors. The Joint Commission reports that, according to an RCA of over 4,000 adverse events, 70% were caused by communication breakdowns. 28 Such breakdowns can include inadequate patient handoffs, interpersonal communication failures, and reluctance to admit a lack of knowledge or failure to seek clarification. Planning and Knowledge Planning and knowledge failures can encompass virtually every aspect of care delivery, and the different types of errors that can be caused by failure in planning and knowledge are almost limitless. 12, 13 It is therefore essential healthcare professionals work together to establish the most effective plan of care for each patient to ensure that all members of the healthcare team have the necessary knowledge and skills to implement the plan of care, and to evaluate the effectiveness and safety of the plan as it is implemented. Systemic or Institutional Failures The Institute of Medicine (IOM) reports medical errors are more often due to poor systems than negligent practitioners. System failures involve poor planning and execution, inappropriate or absent policies and procedures, failure to procure and maintain equipment, failure to hire and retain staff, failure to maintain safe staffing levels, failure to monitor care, and failure to recognize errors and correct the conditions that caused the errors. 12, 13 While systemic failures in communication, infection control, and medication prescribing, dispensing, and administration have contributed considerably to medical error, entrenched healthcare traditions (e.g., using blame and shame, closing ranks, and strategies that minimize legal liability) have played a major role in discouraging disclosure necessary to reduce the risk of medical error. Personal behavior is in one sense the least changeable aspect of medical error prevention. Healthcare professionals are not motivated to disclose medical error if policies and procedures focus on punishment rather than timely reporting and prevention. While individuals bear responsibility for their actions when a medical error occurs, the traditional blame and shame culture of healthcare is counterproductive if the goal is reducing error. First, it discourages voluntary reporting; second, it does not assess whether there was a system contribution to the error; and third, it focuses on assigning blame and punishment, not on why the error occurred, or on error prevention. 12 13 Some suggest healthcare medical error reporting would be more effective if modeled on alternative reporting systems, such as those used in the aviation industry, which has a very high level of
Medical Errors _V2 March 31, 2020 Medical Errors _V2 March 31, 2020 A recent retrospective study used RCA reports of adverse events occurring in Veterans Health Administration EDs to understand the range of events that were happening and to determine the primary causes of these events as well as actions to prevent them. 28 Safety reports from EDs from Veterans Health Administration medical centers across the nation for a two-year period (2015– 2016) were coded by event type, root cause, and recommended actions. The most common adverse events were as follows: delays in care (26.4%), elopements (n14.6%), suicide attempts and deaths by suicide (10.4%), inappropriate discharges (10.4%), and errors in following procedures (9.7%). The most common root cause categories leading to adverse events were knowledge/ safety. Aviation reporting guidelines do not absolve individuals of responsibility and punishment for errors, but instead treat each incident as a complex event with many possible causes and contributing factors. 12, 13 Root Cause Analysis of Adverse Events Reports From Emergency Departments in the Veterans Health Administration The ED is an important area to focus improvement efforts because it serves as the initial point of care for a majority of the population. Since 1997, the number of ED visits per year in the United States has increased by 23%, which amounts to a total of 141.4 million individuals using emergency care services in 2014, more than half of which are for nonurgent reasons. In addition, a large variety and number of conditions are treated, which make errors more likely. Because 70% of errors in the ED are preventable, the IOM identified the ED as a prime area for patient safety improvement. 29
educational deficits (11.4%), policies/procedures needing improvement (11.1%), and lack of standardized policies/procedures (9.4%). 29 Overall, 44.4% of cases were associated with no injury, 22.2% with moderate injury resulting in increased length of stay, 17.4% with major injury resulting in permanent injuries, and 16.0% resulted in catastrophic injury or death (Figure 2). 29 The authors noted that identifying the most severe ED adverse events and their preceding causes permits the development of action plans aligned to address root causes and the prioritization of action plan implementation. 29 ADDRESSING ROOT CAUSES: STRATEGIES FOR REDUCING COMMON MEDICAL ERRORS Human error is inevitable. Although we cannot eliminate human error, we can better measure the problem to design safer systems mitigating its frequency, visibility , and consequences. Strategies to reduce death from medical care should include three steps: 1. Making errors more visible when they occur so their effects can be intercepted. 2. Having remedies at hand to rescue patients. 3. Making errors less frequent by following principles that take human limitations into account (Figure 3). 30 The identification of errors needs to become more transparent. There needs to be standardized data collection and evaluation of the root cause of each error. Punishment is not helpful as it leads to the nondisclosure of errors or risk of error. Both individuals and hospital systems have unique responsibilities in the reduction of medical errors. 30
Figure 2. Injury Severity of all RCA Cases
The authors noted that identifying the most severe ED adverse events and their preceding causes permits the development of action plans aligned to address root causes and the prioritization of action plan implementation. 27 Human error is inevitable. Although we cannot eliminate human error, we can better measure the problem to design safer systems mitigating its frequency, visibility, and consequences. Strategies to reduce death from medical care should include three steps: 1. Making errors more visible when they occur so their effects can be intercepted. 2. Having remedies at hand to rescue patients. 3. Making errors less frequent by following principles that take human limitations into account. 28 ADDRESSING ROOT CAUSES: STRATEGIES FOR REDUCING COMMON MEDICAL ERRORS Figure 3. Individual and System Responsibilities
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The identification of errors needs to become more transparent. There needs to be standardized data collection and evaluation of the root cause of each error. Punishment
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