COMMON CAUSES OF MEDICAL ERRORS

The majority of medical errors are not caused by individual recklessness or the actions of a particular group. More commonly, errors are caused by faulty systems, processes, and conditions that lead people to make mistakes or fail to prevent them. Individuals, of course, should still be held accountable when an error can be attributed to them; however, blaming an individual does little to make the system safer and prevent someone else from committing the same error. A blaming culture can also result in reluctance to disclose or report an error, which may contribute to increased harm to a patient and risk to other patients in future.

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, including:
   • Not seeking advice from peers
   • Misapplying expertise
   • Not formulating a plan
   • Not considering the most obvious diagnosis
   • Conducting healthcare in an automatic fashion
2. Communication issues:
   • Lacking insight into the hierarchy
   • Having no solid leadership
   • Not knowing whom to report a problem to
   • Failing to disclose an issue
   • Having a disjointed system with no problem-solving ability
3. Deficiencies in:
   • Education
   • Training
   • Orientation
   • 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)

Classification of Errors

The classification of different types of errors involved in healthcare are based on human cognitive processes that involve planning, storage, and execution. One such classification system is the Skill, Rule, and Knowledge (SRK)–based approach. It refers to the degree of conscious control that an individual exerts over activities.

SKILL-BASED ERRORS

Errors that occur at the skill-based (automatic) mode involve execution/action failures (slips) and storage/memory failures (lapses). Skill-based errors are associated with familiar and frequently performed tasks that require little conscious attention. Slips are usually errors of inattention or misplaced attention where the intention is correct, but failure occurs while carrying out the activity. Memory lapses occur after formation of a plan and before execution during the time the plan is stored in the brain. They may include instances of forgetting to do something, losing one’s place in the sequence of actions, or even forgetting the overall plan. Examples include omissions of steps in an action or repetition of steps in an activity (Khemani, 2019).

RULE-BASED ERRORS

The rule-based (intuitive) mode refers to rules that may have been learned through education, formal training, and experience. Rule-based processing is used when a person becomes aware that there is a problem. The conditions of the problem are matched with the conditions of problems the individual has encountered in the past. The solution used for the similar situation in the past is then applied using the “if this happens, then do that” rule.

Rule-based mistakes can occur if the current problem is assessed incorrectly, and therefore incorrectly matched to a previous problem, or when a usually good rule is applied at the wrong time. Such mistakes (planning failures) include using a good rule incorrectly or using a bad rule. When rule-based processing includes bypassing rules or safety procedures, it is known as a violation (Khemani, 2019).

KNOWLEDGE-BASED ERRORS

In the knowledge-based (analytical) mode, the person is focused on problem solving, and the task at hand must be carried out in an almost completely conscious manner taking considerable mental effort to assess the problem. This would occur in a situation where a provider is performing a task that is new or when an experienced provider is faced with a completely novel situation and has no experience or rules to fall back on.

In such an instance the person must create a solution. When the solution arrived at is incorrect, the error is called a planning failure or mistake. Knowledge-based mistakes arise from the considerable demands placed on the information-processing capabilities of the provider (Khemani, 2019).