Mistakes happen. This is true in every industry. However, in healthcare, the consequences can be deadly.
Medical errors are a leading cause of death in the United States. Approximately 100,000 Americans die each year because of medical errors, costing the healthcare industry roughly $20 billion. Death by medical error or accident exceeds all other causes of accidental death combined.
Administrative errors account for up to half of all medical errors in primary care. An error can be something as simple as missing or incomplete patient paperwork, which shouldn’t be surprising because providers fill out an average of 20,000 forms per year.
There are also medication errors, which are defined as “any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient or consumer. Medication errors are a common cause of malpractice claims against physicians.
High error rates with serious consequences are most likely to occur in intensive care units, operating rooms, and emergency departments. Even physician burnout can lead to increased medical errors and a lower quality of patient care.
Not all medical errors are reported, sometimes because some employees don’t want to admit to an error for fear of punishment from supervisors. Not all healthcare provider organizations have a system in which employees can accurately report errors to increase patient safety and improve quality of care.
Common Causes of Medical Errors
The Agency for Healthcare Research and Quality (AHRQ) lists eight common root causes of medical errors:
- Communication problems
- Inadequate information flow
- Human problems
- Patient-related issues
- Organizational transfer of knowledge
- Staffing patterns and workflow
- Technical failures
- Inadequate policies
Problems that commonly occur during providing healthcare are adverse drug events and improper transfusions, misdiagnosis, under- and overtreatment, surgical injuries and wrong-site surgery, suicides, restraint-related injuries or death, falls, burns, pressure ulcers and mistaken patient identities. Other reasons for healthcare errors include low health literacy, inadequate provider follow-up and incorrect medication dispensing and administration. The American Hospital Association (AHA) lists these common factors that contribute to medication errors:
- Unavailable patient information
- Unavailable drug information
- Miscommunication of drug orders
- Problems with labeling, packaging and drug nomenclature
- Drug standardization, storage, and stocking
- Drug device acquisition, use and monitoring
- Environmental stress
- Limited staff education
- Quality improvement processes and risk management
The Importance of Communication and Collaboration Among Clinicians
As noted by AHRQ, communication problems are one of the top common root causes of medical errors. A review of reports from a study conducted by The Joint Commission revealed more than 70 percent of medical errors are the direct result of communication failures. Approximately 80 percent of serious medical errors involve miscommunication between caregivers during the transfer of patients.
The Institute for Healthcare Advancement (IHA) created a list of the 10 most common errors providers make when communicating with patients:
- Creating prescription drug instructions that are written at 11th grade reading level or higher, rather than 5th grade reading, the level at which the majority of the country’s population reads
- Communicating in medical jargon when it’s not necessary.
- Sending patients to the Internet as a means of better explaining instructions and follow-up care.
- Handing out reading material that is printed in a font size too small for the patient.
- Not using simple visuals for medical instruction which can enhance patient understanding.
- Not recognizing that a patient’s response of “yes” or a simple nod might mean the patient is merely being polite but actually does not understand what they have just been told.
- Failing to demonstrate cultural awareness and sensitivity in patient encounters
- Talking too quickly to the patient and not allowing time for the patient to ask questions in response
- Not providing medical information in the patient’s first language
- Not taking time to explain the meaning of prescription bottle labels such as “TAKE WITH FOOD.” Studies show that even simple labels such as this, written at a 1st or 2nd grade reading level, are not understood universally as people have stuffed pills into solid foods and then eaten the food without liquid.
Communication and collaboration among clinicians, especially during transitions of care, is an important step in decreasing the number of medical errors. Effective communication can lead to better health outcomes through reduced medication errors.
Hospitals that have updated outdated communications systems have managed to not only reduce medical errors but also improve patient safety, increase productivity, reduce patient wait times, increase patient throughput and significantly cut costs. Even after a medical error does occur, open communication from providers to patients decreases emotional impacts and diminishes patient avoidance of doctors and organizations involved in errors.