The 8 Most Common Root Causes of Medical Errors
By Anne Carrie, Updated March 16, 2021
A recent study from Johns Hopkins suggests that medical errors are now the third-leading cause of death in the U.S., having surpassed strokes, Alzheimer’s, and diabetes. In addition, one in seven Medicare patients receiving care in a hospital are victims of a medical error. However, medical errors can occur in almost any healthcare setting including hospitals, clinics, surgery centers, medical offices, nursing homes, pharmacies, and patients’ homes. This post will explore the most common causes of medical errors.
A few of the most common types of medical errors include: medication errors, errors related to anesthesia, hospital acquired infections, missed or delayed diagnosis, avoidable delay in treatment, inadequate follow-up after treatment, inadequate monitoring after a procedure, failure to act on test results, failure to take proper precautions, and technical medical errors.
Studying these mistakes, learning how to prevent, monitor, and respond to them is key to changing the standards of care. By working to eliminate common medical errors, healthcare systems and providers can protect patients, protect themselves, improve standards of care, and lower costs.
The Eight Common Root Causes of Medical Errors
According to the Agency for Healthcare Research and Quality, there are eight common root causes of medical errors which include:
Communication breakdowns are the most common causes of medical errors. Whether verbal or written, these issues can arise in a medical practice or a healthcare system and can occur between a physician, nurse, healthcare team member, or patient. Poor communication often results in medical errors.
Inadequate Information Flow
Information flow is critical in any healthcare setting, especially within different service areas. Insufficient information flow happens when necessary information does not follow the patient when they are transferred to another facility or discharged from one component or organization to another. Inadequate information flow can cause the following problems:
- The lack of crucial information when needed to influence prescribing decisions.
- Lack of appropriate communication of test results.
- Poor coordination of medication orders for transfer of care.
Human problems occur when standards of care, policies, processes, or procedures are not followed properly or efficiently. Some examples include poor documentation and labeling of specimens. Knowledge-based errors also occur when individuals do not have adequate knowledge to provide the care that is required at the time it is needed.
These may include inappropriate patient identification, inadequate patient assessment, failure to obtain consent, and insufficient patient education.
Organizational Transfer of Knowledge
These issues can include insufficiencies in training and inconsistent or inadequate education for those providing care. Transfer of knowledge is critical in most areas specifically where new employees or temporary help is used.
Staffing Patterns and Workflow
Inadequate staffing alone does not lead to medical errors but can put healthcare workers in situations where they are more likely to make a mistake.
Technical failures can include complications or failures with medical devices, implants, grafts, or pieces of equipment.
Often, failures in the process of care can be traced to poor documentation and non-existent, or inadequate procedures.