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The analysis progresses from special causes in clinical processes to common causes in organizational processes and systems and identifies potential improvements in these processes or systems. The goal is to decrease the likelihood of such events in the future by implementing strategies to prevent the event from occurring again. CATEGORIES OF MEDICAL ERRORS
one healthcare associated infection. 21 The main types of infection include: pneumonia (22%), surgical site infections (22%), gastrointestinal infections (17%), and device associated infections, which include central line infections, catheter-associated UTI, and ventilator-associated pneumonia (26%). 22 It is impossible to estimate the percentage of hospital acquired infections that are avoidable, but evidence shows that many of these infections can and should be prevented. For example, failure to conform to hand hygiene standards can lead to preventable infections. 21 Surgical errors: Wrong-site, wrong-procedure, wrong-patient errors should never occur and indicate serious safety problems within an organization. Recent studies show that these types of errors occur in about one of 112,000 surgical procedures or that an individual hospital would experience such an error every five to 10 years. However, these data sets only include procedures in the operating room. If procedures performed in other settings, such as ambulatory surgery centers, were to be included, the rate of such errors may be significantly higher. 23 Pharmacy errors: Pharmacy errors can involve such issues as the preparation or processing of a prescription or giving incorrect directions to patients. Researchers at a tertiary care medical center in Houston, Texas, recently monitored 1,887,751 medication orders, 92 medication error events, and 50 pharmacists. They determined that the overall error rate was 4.87 errors per 100,000 verified orders. Pharmacy errors were associated with workload, work environment, and number of pharmacists per shift. Factors such as the type of pharmacy degree, age, experience, and the number of years at an institution may also influence the error rate. 24 Laboratory errors: Errors made in the laboratory can be technical, procedural, or the result of poor communication. The ECRI Institute evaluated 2,420 mistakes that occurred between 2011 and mid-2013. Only 4% of reported potentially harmful errors occurred in the laboratory itself. Nearly 75% of mistakes occurred in the pre-analytic stage, defined as the time frame in which tests are selected and ordered, specimens are identified and transported, and patients are prepared. Such mistakes were more likely to be linked to labels that had the wrong patient’s name, the wrong specimen ordered, and incomplete or missing information. The other 22% occurred in the post-analytic stage, when results were interpreted, reported, or stored. 25
ROOT CAUSE FACTORS THAT CONTRIBUTE TO MEDICAL ERRORS The causes and prevention of medical errors are the focus of considerable academic and professional attention. For accreditation purposes, the Joint Commission requires that healthcare institutions have a comprehensive process for the systematic analysis of sentinel events. 26 Reporting of sentinel events by accredited organizations is voluntary, and it is estimated that less than 2% of all sentinel events that occur in healthcare are reported to The Joint Commission. The most frequently reported sentinel events in 2020 were fall (n=170), unintended retention of a foreign object (n=106); suicide (n=81); delay in treatment (n=76); wrong side-surgery (n=68); assault/ rape/sexual assault (n=47); fire (n=30); clinical alarm response (n=27); self-harm (n=24); and medication management (n=24). 27 The Office of Quality and Patient Safety at The Joint Commission works with organizations reporting sentinel events to identify contributing factors and actions the organization can take to reduce risk. 27 The root cause analysis (RCA) process is one of the most commonly used tools by institutions to optimize patient care and enact measures to mitigate adverse events. RCA is primarily based on system-level process. The RCA starts with a designated team that reviews and identifies required changes at the systemic level, improving performance and reducing the likelihood of another sentinel event. Failure to perform an RCA within 45 days of the occurrence of a sentinel event may result in the healthcare institution being placed on an ‘accreditation watch,’ which is public information. Repeat violations may result in an onsite review by the Joint Commission that may jeopardize accreditation. The Joint Commission has created a framework and series of 24 questions to aid in organizing an RCA. This framework is recommended to be used as a general template when preparing the RCA report that will eventually be submitted to the Joint Commission after thorough evaluation. 26 The 24-question framework recommended by the Joint Commission considers a variety of situational factors that may have contributed to a sentinel event. This includes examining the systematic process, human factors, equipment malfunctions, environmental factors, uncontrollable external factors, organizational factors, staffing and qualifications, contingency plans, performance expectations, informational disruptions, communication, environmental risks, training, and technology (Table 1). 26 Prevention strategies typically address the three most common causes of medical errors: communication, planning and knowledge, and systemic or institutional failure. 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.
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Many preventable adverse events can be associated with more than one type of medical error. Although there are many different ways to categorize medical error, and categories may overlap, the following classifications are common. •
Misdiagnosis/Diagnostic errors: Diagnosis errors are errors that occur when a diagnosis is missed, wrong, or delayed. 15 Preventing medical misdiagnosis is a recognized national public health priority. 16 In their landmark 2015 report Improving Diagnosis in Healthcare, the National Academy of Medicine (NAM) stated that “most people will experience at least one diagnostic error in their lifetime, sometimes with devastating consequences.” 17 Diagnostic error rates in real-world practice are not known, but a commonly cited estimate is that 10–15% of all diagnoses are incorrect. 16 A 2021 review article found that missed vascular events, infections, and cancers account for 75% of serious harms from diagnostic errors and 15 diseases account for nearly half of all serious misdiagnoses. 16 Systems or process errors: Systems or process errors involve predictable human failings in the context of poorly designed systems. 18 Active errors: Active errors nearly always involve frontline staff members and occur at the point of contact between a human and some part of a larger system. 18 Latent errors: Sometimes referred to as “accidents waiting to happen,” latent errors involve failures of organization or design (e.g., systems and processes) that allow active errors to cause harm. 18 Medication errors: Medication errors are “any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer.” 19 The FDA receives approximately 100,000 reports each year associated with suspected medication error. These reports come from drug manufacturers, healthcare professional, and consumers through MedWatch, the Agency’s safety information and adverse event reporting program. 20 Infection-related errors: According to the U.S. Centers for Disease Control and Prevention (CDC) on any particular day, approximately one in 25 patients has at least
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