LEARNING OUTCOME AND OBJECTIVES:  Upon completion of this course, you will understand current, evidence-based interventions to prevent medical errors in the practice setting. Specific learning objectives to address potential knowledge gaps include:

• Define medical errors and associated terminology.
• Describe factors that impact the occurrence of medical errors.
• Review the most common medical errors and processes to improve patient outcomes.
• Identify populations with special vulnerability to medical errors.
• Discuss Florida’s statutory requirements for addressing medical errors.

INTRODUCTION

It would seem obvious and essential that every healthcare encounter a person has should be safe and free from harm. Unfortunately, this is not always the case. Although the vast majority of Americans are having positive experiences with the healthcare system, many report having personally experienced a “medical error.” Errors occur in hospitals, clinics, surgery centers, dialysis centers, medical offices, dental offices, nursing homes, pharmacies, and even in patients’ homes—anywhere patients receive care.

Medical errors are a serious public health issue, with every patient involved in the healthcare system a potential recipient of harm. Injuries and death can occur, for example, when patients receive a wrong medication or dose of medication, experience mistakes in surgery, receive treatments meant for another patient, experience a fall in the hospital, develop a pressure injury, or are subjected to a misdiagnosis, misinterpreted medical order, or equipment failure.

Errors can occur at any point while in the healthcare system. Analyzing why medical errors happen has traditionally been focused on the human factor, concentrating on individual responsibility for making an error, and the solutions have involved training or retraining, additional supervision, or even disciplinary action. The alternative to this individual-centered approach is a system-centered approach, which assumes that humans are fallible and that systems must be designed so that humans are prevented from making errors.

Acknowledging that errors happen, learning from them, and working to prevent errors in the future are important goals and represent a major change in the culture of healthcare—a shift from blame and punishment to analysis of the root causes of errors and the creation of strategies to reduce the risk of errors. In other words, healthcare organizations must create a culture of safety that views medical errors as opportunities to improve the system. Every person on the healthcare team has a role in making healthcare safer for patients and workers (Rodziewicz et al., 2021).