Reducing Medical Errors: TAXONOMY OF ROOT CAUSES
Filed under: Health
The implementation of the Condition C criteria has helped to convert some potential deaths to near-misses; just as important, it has allowed for a case-based analysis of the root causes of these near-misses so that we can implement changes and begin to make process improvements. The following flexible taxonomy was developed in an effort to understand the fundamental reasons behind medical errors reported at UPMC and to determine the types of interventions that would most effectively address the antecedent causes of these events. A number of such taxonomies in the literature address the cognitive psychology of errors in general and medical errors in particular. We have found it useful to develop our own system in order to communicate better with the local health care delivery team. Our ability to recall errors of a similar type in the local environment is helpful in educating individuals about the repetitive nature of errors and the need for systemic corrective measures. Our taxonomy is presented as follows:
- Bad things happen to sick people. Many life-threatening errors, including medication mistakes, improper procedures, and incorrect diagnoses, become evident when the clinical courses of the sickest patients are examined. Because the consequences of these errors are more severe than with healthier patients, the incentives to correct them are made more obvious.
- The climactic event is the result of a chain of errors. Usually, there is no single cause of an accident; the problem often results from a series of accidents. For example, an error in decision-making, such as a misread x-ray, might set in motion a chain of occurrences that lead to an adverse event.
- The most experienced clinician is not at the bedside. We have noticed that medical errors often occur at night, when the hospital is typically staffed by the least experienced physicians, who are often overworked and sleep-deprived; this can lead to impaired judgment in unexpected crisis situations. Our analysis of a number of such events has led us to establish the presence of several groups of skilled specialty physicians and surgeons in the hospital at all times.
- Patients are not monitored during transport. Patients are often transported without being monitored, without their medications, or without adequate oxygen supplies in the portable tanks.
- Procedures are hindered by dither and delay. Inexperienced physicians sometimes do not know when to call for help, which can result in inappropriate care or in delayed access to the proper care. Even the act of calling for help can use up valuable patient care time. Prompt responses by the crisis team and establishing the Condition C criteria have partially reduced the incidence of delayed responses in medical crises.
- Distress in patients is not diagnosed. Health care providers are often inadequately prepared to recognize the various types of distress in patients. For example, many nurses have not been trained to identify respiratory distress, and physicians do not always diagnose major depression or the underlying physiological changes responsible for confusion or delirium. Educational programs directed at these deficits in training have been effective in reducing errors stemming from a lack of knowledge.
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- Bedside procedures are performed inadequately. Procedures performed at the patient’s bedside (e.g., inserting central venous lines, placing small-bore feeding tubes, and placing chest tubes) are often hindered by a lack of training, credentialing, supervision, and equipment. We have established credentialing and privileging criteria for most bedside procedures in addition to developing a training program that uses computerized manikins as simulators rather than live patients.
- Patient “hand-offs” are poorly coordinated. Errors can occur when nurses’ shifts change or when patients are moved from one unit to another, leading to gaps in coverage by the staff and in loss of patient information.
- Equipment design and maintenance are faulty. Medical errors can result from faulty or poorly designed defib-rillators, bronchoscopes, oxygen tanks, and other devices. For example, standard oxygen tanks carry an insufficient supply for most patients who are undergoing diagnostic studies at unmonitored sites within the hospital, such as in the radiology department.
- Medications are improperly prescribed or dispensed. According to the IOM report, more than 7,000 Americans die each year as a result of medication errors, which include the prescribing or dispensing of the wrong drugs. Of particular concern are narcotics and other drugs that are administered via patient-controlled analgesia (PCA) pumps, which can cause serious harm to patients when used incorrectly. A miscalculation of a morphine dose, for example, can be lethal. Computerized ordering, dispensation, and administration systems can partially solve these problems. The Institute for Safe Medication Practices provides a monthly inventory of avoidable errors. kamagra soft tablets