Patient Safety - Causes of Healthcare Error

Causes of Healthcare Error

See also Healthcare error and Healthcare error proliferation model

The simplest definition of a health care error is a preventable adverse effect of care, whether or not it is evident or harmful to the patient. Errors have been, in part, attributed to:

Human Factors

• Variations in healthcare provider training & experience, fatigue, depression and burnout.
• Diverse patients, unfamiliar settings, time pressures.
• Failure to acknowledge the prevalence and seriousness of medical errors.

Medical complexity

• Complicated technologies, powerful drugs.
• Intensive care, prolonged hospital stay.

System failures

• Poor communication, unclear lines of authority of physicians, nurses, and other care providers.
• Complications increase as patient to nurse staffing ratio increases.
• Disconnected reporting systems within a hospital: fragmented systems in which numerous hand-offs of patients results in lack of coordination and errors.
• Drug names that look alike or sound alike.
• The impression that action is being taken by other groups within the institution.
• Reliance on automated systems to prevent error.
• Inadequate systems to share information about errors hamper analysis of contributory causes and improvement strategies.
• Cost-cutting measures by hospitals in response to reimbursement cutbacks.
• Environment and design factors. In emergencies, patient care may be rendered in areas poorly suited for safe monitoring. The American Institute of Architects has identified concerns for the safe design and construction of health care facilities.
• Infrastructure failure. According to the WHO, 50% of medical equipment in developing countries is only partly usable due to lack of skilled operators or parts. As a result, diagnostic procedures or treatments cannot be performed, leading to substandard treatment.

The Joint Commission's Annual Report on Quality and Safety 2007 found that inadequate communication between healthcare providers, or between providers and the patient and family members, was the root cause of over half the serious adverse events in accredited hospitals. Other leading causes included inadequate assessment of the patient's condition, and poor leadership or training.

Common misconceptions about adverse events are:

• "'Bad apples' or incompetent health care providers are a common cause." Many of the errors are normal human slips or lapses, and not the result of poor judgment or recklessness.
• "High risk procedures or medical specialties are responsible for most avoidable adverse events". Although some mistakes, such as in surgery, are easier to notice, errors occur in all levels of care. Even though complex procedures entail more risk, adverse outcomes are not usually due to error, but to the severity of the condition being treated. However, USP has reported that medication errors during the course of a surgical procedure are three times more likely to cause harm to a patient than those occurring in other types of hospital care.
• "If a patient experiences an adverse event during the process of care, an error has occurred". Most medical care entails some level of risk, and there can be complications or side effects, even unforeseen ones, from the underlying condition or from the treatment itself.