Most Common Root Causes of Medical Errors
The demonstration project grantees identified a diverse group of factors that cause medical errors. The factors can generally be group into eight categories and how these factors contribute to medical errors is described below:
1. Communication problems represent the most common cause of medical errors noted by the error reporting evaluation grantees. Communication problems can cause many different types of medical errors and can involve all members of a health care team. Communication failures (verbal or written) can take many forms, including miscommunication within an office practice as well as miscommunication between different components of the health care system or health care providers working different shifts. These problems can occur between health care providers such as primary care physicians and emergency room personnel, attending physicians and ancillary services, and nursing homes and patient services in hospitals. Communication problems can result in poorly documented or lost information on laboratory results, diagnostic testing, or medication information, and can occur at any point along the communication chain. Communication problems can also occur within a health care team in one location, between
providers at different locations, between health care teams and other non-clinician providers (such as labs or imaging centers), and between health care providers and patients.
2. Inadequate information flow can include problems that prevent:
The availability of critical information when needed to influence prescribing decisions.
Timely and reliable communication of critical test results.
Coordination of medication orders at points of interface or transfer of care.
Information flow is critical between service areas as well as within service areas in health care. Often, necessary information does not follow the patient when he or she is transferred to another service or is discharged from one component or organization to another.
3. Human problems relate to how standards of care, policies, or procedures are followed. Problems that may occur include failures in following policies, guidelines, protocols, and processes. Such failures also include sub-optimal documentation and poor labeling of specimens. There are also knowledge-based errors where individuals do not have adequate knowledge to provide the care that is required for any given patient at the time it is needed.
4. Patient-related issues can include improper patient identification, incomplete patient assessment, failure to obtain consent, and inadequate patient education. While patient related issues are listed as a separate cause by some reporting systems, they are often nested within other human and organizational failures of the system.
5. Organizational transfer of knowledge can include deficiencies in orientation or training, and lack of, or inconsistent, education and training for those providing care. This category of cause deals with the level of knowledge needed by individuals to perform the tasks that they are assigned. Transfer of knowledge is critical in areas where new employees or temporary help is often used. The organizational transfer of knowledge addresses how things are done in a particular organization or health care unit. This information is often not communicated or transferred. Organizational transfer of knowledge is also a critical issue in academic medical centers where physicians in training often rotate through numerous centers of care.
6. Staffing patterns/work flow can cause errors when physicians, nurses, and other health care workers are too busy because of inadequate staffing or when supervision is inadequate. Inadequate staffing, by itself, does not lead directly to medical errors, but can put health care workers in situations where they are much more likely to make an error.
7. Technical failures include device/equipment failure and complications or failures of implants or grafts. In many instances equipment and devices such as infusion pumps or monitors can fail and lead to significant harm to patients. In many instances inadequate instructions or poorly designed equipment can lead to patient injury. Often technical failure of equipment is not properly identified as the underlying cause of patient injury, and it is assumed that the health care provider made an error. A complete root cause analysis often reveals that technical failures, which on first review are not obvious, are present in an adverse event.
8. Inadequate policies and procedures guiding the delivery of care can be a significant contributing factor in many medical errors. Often, failures in the process of care can be traced to poorly documented, non-existent, or clinically inadequate procedures.
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