CAUSES AND TYPES OF MEDICAL ERRORS

Medical errors are likely to occur in situations where providers are challenged to make decisions in dynamic, fast-paced, complex environments under tight time constraints. Errors stem from technical, organizational, or human factors that set off a chain reaction that could result in an adverse event (Carver et al., 2020).

The ten most common causes of medical error include:

  1. Altered ability to make good judgments and quick decisions (e.g., misapplying expertise)
  2. Ineffective communication (the most common cause)
  3. Deficiencies in education, training, orientation, and experience
  4. Inadequate methods of identifying patients, incomplete assessment on admission, failing to obtain consent, and failing to provide education to patients
  5. Inadequate policies to guide healthcare workers
  6. Lack of consistency in procedures
  7. Inadequate staffing and/or poor supervision
  8. Technical failures associated with medical equipment
  9. No audits in the system
  10. No one prepared to accept responsibility or change the system
    (Rodziewicz et al., 2021)
ROOT CAUSE ANALYSIS

Root cause analysis (RCA) is a structured method used to analyze serious adverse events. When an adverse event occurs, a root cause analysis identifies underlying problems that increase the likelihood of errors while avoiding focusing on mistakes made by individuals. The approach identifies both active errors and latent errors and is one of the most widely used retrospective methods for detecting safety hazards.

RCAs follow a prespecified protocol, beginning with development of a multidisciplinary team that will define and study the problem. This process includes:

  • Determining what happened
  • Identify contributing factors
  • Measuring, collecting, and assessing data
  • Identifying the root cause
  • Designing and implementing a corrective action plan
  • Developing measures of effectiveness and ensuring their success
  • Evaluating implementation of improvement efforts
  • Taking additional action
  • Communicating the results

The ultimate goal of RCA is to prevent future harm by eliminating the latent errors that so often underlie adverse events (AHRQ, 2020).

Surgical Errors

Wrong-site, wrong-procedure, and wrong-patient surgical errors are relatively rare. It is estimated that in the United States such errors occur in approximately 1 of 112,000 surgical procedures and are infrequent enough that an individual hospital would only experience one such incident every 5 to 10 years. However, this includes only procedures performed in an operating room. If procedures performed in other settings such as ambulatory surgery are included, the rate of error may be much higher (AHRQ, 2019d).

Retained foreign bodies (also called retained surgical items) and unintentionally retained foreign objects are defined as objects retained after skin closure following an invasive procedure. Most unintended retained foreign bodies are associated with failures in leadership, communication, or other human factors that should be under the control of the operating team (Pellegrini, 2019).

Anesthesia-related adverse events may include inadvertent gas flow change, premature extubation, or breathing circuit connection error (Rayan et al., 2019).

The WHO Surgical Safety Checklist was developed after extensive consultation aimed at decreasing errors and adverse events, and increasing teamwork and communication in surgery. This checklist has gone on to show significant reduction in both morbidity and mortality and is now used by a majority of surgical providers around the world (WHO, 2021).

Medication Errors

Every year in the United States, 7,000 to 9,000 people die due to a medication error. In addition, hundreds of thousands experience but often do not report an adverse reaction or other complication related to a medication. Clinicians have access to more than 10,000 prescription medications, and nearly one third of adults in the United States take five or more medications.

Each year, adverse drug events account for nearly 700,000 emergency department visits and 100,000 hospitalizations. Nearly 5% of hospitalized patients experience an adverse drug event, making them one of the most common types of inpatient errors. Ambulatory patients may experience adverse drug events at even higher rates, and transition in care is also a well-documented source of preventable harm related to medications (Tariq et al., 2021; AHRQ, 2019e).

Medication errors may be due to human errors but often result from a flawed system with inadequate backup to detect mistakes. Most medication errors occur when drugs are being prescribed and transcribed. Medication errors may occur at any step including:

  • Ordering/prescribing. The clinician must select the appropriate medication, dose, frequency, and duration.
  • Transcribing. In a paper-based system, an intermediary must read and interpret the prescription correctly.
  • Dispensing. The pharmacist must check for drug-drug interactions and allergies and release the appropriate quantity of the medication in the correct form.
  • Administering. The correct medication must be supplied to the correct patient at the correct time, either by a nurse, other trained staff, patient, or caregiver.
  • Monitoring. This includes laboratory tests, side effects, effectiveness of therapeutic action, and vital signs.
  • Documenting. The name, strength, and quantity of drug; the date and time administered; and the name of the person administering the drug must be entered in the patient’s medication administration record in a timely manner.
    (Tariq et al., 2021)

(See also “Occupational Therapy and Medication Management” later in this course.)

Tubing Misconnections

The FDA reports that medical device misconnections can occur when one type of medical device is attached in error to another type of medical device that performs a different function. Tubing misconnections can occur for several reasons, including:

  • Similar design of many connectors and the widespread use of connectors with similar shapes and in similar sizes
  • Human error arising from conditions such as:
    • Multiple connections for one patient
    • Poor lighting
    • Lack of training
    • Time pressure
    • Fatigue
    • High-stress environment
    (FDA, 2018)

Attempts to prevent device misconnections have included color-coding, labels, tags, and training. However, these methods alone have not effectively solved the problem, because they have not been consistently applied, nor do these methods physically prevent the misconnections.

In order to reduce the chances of tubing misconnections, non-Luer lock connections have been introduced. These include the NR-Fit connector for neuraxial and regional anesthesia catheters and the Enfit connectors for feeding tubes.

Healthcare-Associated Infections (HAIs)

HAIs are infections that occur while receiving healthcare in a hospital or other healthcare facility and that first appear 48 hours or more after admission or within 30 days after having received healthcare. HAIs are considered system failures and are often preventable (CDC, 2020a).

Types of healthcare-associated infections include:

  • Catheter-associated urinary tract infections
  • Surgical site infections
  • Central line-associated bloodstream infections
  • Peripheral IV catheter-related bloodstream infections
  • Clostridioides difficile (C. diff) infections
  • Multidrug-resistant organism infections

One of the most important reasons in healthcare settings for the spread of infectious bacteria, some of which are antibiotic-resistant and can prove life threatening, is the failure of physicians, nurses, and other caregivers to practice basic hand hygiene. Studies show that on average healthcare providers clean their hands less than half of the times they should, contributing to the spread of HAIs.

Prevention measures include:

  • Following infection control policies and procedures
  • Practicing hand hygiene measures
  • Keeping environment and equipment clean
  • Utilizing sterile technique when appropriate
  • Using antibiotics when appropriate
    (CDC, 2020b)

Errors Related to Medical Devices and Equipment

Technology is believed to improve healthcare efficiency, increase quality of care, promote safety, and lower cost. This same technology, however, may result in errors and adverse events. Since there are approximately 5,000 types of medical devices used by millions of healthcare providers around the world, device-related errors are inescapable.

Occupational therapists use different types of physical agent modalities, such as therapeutic ultrasound, electrical stimulation (i.e., TENS or NMES), or neurofeedback, that could be hazardous, resulting in a harm to patients. For example, water and electricity mixed may result in shock hazard, and improper use of equipment can result in harm to both patient and therapist.

Therapists and therapy departments must ensure patient safety by establishing protocols to routinely maintain, repair, and monitor the condition of equipment and assistive devices and to address work practices, which should include:

  • Visual inspection of cords
  • Visual inspection of equipment before using
  • Ensuring all electrical service near sources of water is properly grounded
  • Ensuring proper technique and body mechanics when using devices/equipment, in order to minimize risk of injury (both acute and chronic) to therapist and/or patient
    (OSHA, 2021)

Each year the FDA receives several hundred thousand reports of suspected device-associated deaths, serious injuries, and malfunctions. Mandatory reporting of such events must be done by manufacturers, importers, and device user facilities. Healthcare professionals, patients, caregivers, and consumers are also encouraged to voluntarily report adverse events to MedWatch, the FDA’s safety information and adverse event reporting program.

User facilities must report suspected medical device-related deaths to both the FDA and the manufacturer. A user facility is not required to report a device malfunction but can voluntarily advise the FDA of such product problems. The FDA uses the reported information to monitor device performance, detect potential device-related safety issues, and contribute to benefit-risk assessments of these products (FDA, 2020).

(See also “Adverse Incident Reporting Requirements” later in this course.)

Falls

Falls are the most common type of accidents in people 65 years of age and older. Falls in institutional settings occur more frequently and are associated with greater morbidity than falls that occur in the community. Approximately 50% of individuals in the long-term care setting fall yearly (Appeadu & Bordoni, 2020; Kiel, 2020).

Preventing falls involves assessing patients for fall risk, developing a personalized plan of care, and utilizing consistent preventive interventions.

RISK ASSESSMENT

Falls risk can be categorized as either intrinsic or extrinsic. Intrinsic factors include issues that are unique to the individual and concern medical, psychological, and physical issues such as advanced age, inner ear disorders, and lower extremity weakness (Appeadu & Bordoni, 2020). Extrinsic factors generally can be changed and address environmental risks that patients encounter, such as use of restraints, dim lighting or glare, ill-fitting or inappropriate footwear (AHRQ, 2017).

Older patients are not the only population at risk. Any patient who has had excessive blood loss may experience postural hypotension, increasing the risk of falling. Maternity patients or other patients who have epidural anesthesia are at risk for falls due to decreased lower-body sensation (AHRQ, 2017).

While some institutions have created their own fall risk assessment tools, tools that have been extensively studied and recommended include:

  • Morse Fall Scale
  • STRATIFY Scale
  • Schmid Fall Risk Assessment Tool
  • Berg Balance Scale

Tailored prevention interventions may include:

  • Physical therapy evaluation/treatment for gait instability or other risk factors
  • Occupational therapy evaluation and intervention
  • Toileting schedule for incontinence
  • Continuous virtual monitoring for agitation, confusion, or impaired judgment
  • Pharmacy consults for medication side effects
    (Dykes et al., 2018)
STEADI (STOP ELDERLY ACCIDENTS, DEATHS AND INJURIES)

The Centers for Disease Control and Prevention’s STEADI initiative is a coordinated approach for the implementation of practice guidelines for fall prevention in community-dwelling adults. Recommendations include:

  • Screening for fall risk annually, or any time the patient presents with an acute fall
  • Assessing those who are found to be at risk
  • Intervening to reduce identified risk factors
    (CDC, 2020c)

PREVENTION AND TREATMENT

Occupational therapists address the patient and environment in order to maximize independence, and they work with patients, families, and interdisciplinary team members on ways to support fall prevention initiatives.

Occupational therapists collaborate with patients and caregivers to assess a patient’s home environment for safety and to evaluate the person for limitations which may contribute to falls. The therapist makes recommendations that most often include a combination of modifications to the home to remove safety hazards and activities to improve the person’s physical abilities to perform daily tasks safely.

OTs can also assist in falls prevention through consultation with staff working in community centers, nursing homes, and assisted living facilities to identify environmental factors that contribute to falls and assist in implementing occupational therapy strategies that can improve safety. Occupational therapists also work with patients to assist in breaking the cycle of inactivity and sedentary lifestyle that increase the risk of falling (AOTA, 2021a).

Some specific fall risk factors addressed by occupational therapy include:

  • Lower-extremity weakness
  • Impaired balance
  • Cognitive impairment
  • Urinary incontinence
  • Sensory impairment
  • Fear of falling
  • Side effects of medication
  • Throw rugs and loose carpeting
  • Lighting and glare
  • Pets
  • Clutter
  • Uneven sidewalks and thresholds
  • Unstable or nonexistent handrails

Occupational therapists can review an individual’s home to:

  • Make certain it is safe and easy to get items used on a regular basis, placing everyday items on the lowest shelves to avoid using stepstools and chairs
  • Arrange furniture to provide room to walk freely
  • Keep stairs clutter-free
  • Recommend installing railings and grab bars throughout the home, and consider a bed rail to assist when getting out of bed
  • Recommend nonslip strips or rubber mat on the floor of tub or shower, and nonskid bath mat on the floor
  • Evaluate lighting and recommend additional lighting in potentially unsafe areas or routine work areas
  • Ensure lighting provides good illumination while reducing glare
  • Help create a plan for cleaning up spills if unable to bend down to do so
  • Assist to stay active to maintain overall strength, endurance, and balance
  • Recommend ways to safely continue doing enjoyable things
    (AOTA, 2021b)
CULTURE OF SAFETY

Among their efforts to reduce medical errors, healthcare facilities must consider changes in organizational culture. One such strategy involves creating a “culture of safety,” which encompasses the following key features:

  • Acknowledging the high-risk nature of an organization’s activities and the determination to achieve consistently safe operations
  • Fostering a blame-free environment where individuals are able to report errors or near misses without fear of reprimand or punishment
  • Encouraging collaboration across ranks and disciplines to seek solutions to patient safety problems
  • Committing organizational resources to address safety concerns
    (AHRQ, 2019c)