Root Cause of Medical
Lucian Leape, M.D. et al. broadly characterize the types of errors that result in medical injury. He found that error could be associated with specific factors. He also found evidence that the current medical culture promotes dishonesty and concealment of errors to a degree that prevents learning and safety improvement.
linked "slips" with
distractions that disrupt the routine completion of a task. He linked "mistakes" with
applying the wrong rules when processing information. He linked "knowledge
deficit errors" to action in the absence of critical information.
He also found that physical and psychological factors including: fatigue,
alcohol, drugs, illness, boredom, frustration, fear, anxiety and anger
could increase the probability of error occurrence.
The efforts of Leape and many others have forced an examination of adverse outcomes. A number of methodologies are currently being used to identify, quantify and reduce the effects of errors in healthcare. Root Cause Analysis (RCA) is a retrospective technique used to identify contributing factors and effective mitigating actions. Failure Mode and Effects Analysis (FMEA) focuses on what could go wrong and what can be done about it. Expect your healthcare organization to institute a combination of these techniques when an adverse event is identified.
The Agency for Healthcare Research and Quality through their Patient Safety Initiative (PSI) has identified common root causes of medical errors. They grouped factors that contribute to medical errors into eight categories.
(8 PSI categories with adapted nursing perspective )
problems were found to be the most common root cause of medical errors. Miscommunications
can occur anytime information is transferred between patient and provider
or between the multitude of entities that compose a modern healthcare system.
Nurses are often the hub of patient data as it flows between departments.
Multiple modes of electronic communication/documentation may be incorporated
into nursing practice including text, audio, and video. Ideally, all patient
care communication should be archived. Communications that are not text-based
should follow a standard convention that includes: 1. (sender-message),
2. followed by a (receiver-message restatement), 3. followed
by a sender-affirmation).
- Inadequate information flow:
- Effective health
information technology is timely, secure, transferable and accessible
by authorized care providers at the point of care.
- Point of Care Interface should incorporate: e-charting, continuous archived patient monitoring, automatic provider alert and decision guidance.
- Human problems relate to how standards of care, policies, or procedures are implemented. It is not enough to create and compile rules. Administrators must design systems that measurably produce compliance and reduce patient harm.
- Patient-related issues can include improper patient identification, incomplete patient
assessment, failure to obtain consent, and inadequate patient
education. Enlisting greater patient participation is currently a popular safety theme. While this may be a useful at the margins, it is unethical to shift the burden of self-defense on to the patient. The responsibility for assessment, treatment and outcome rests squarely upon the provider and healthcare fiduciaries.
- Organizational transfer of knowledge can include deficiencies in orientation or training, and lack of, or
inconsistent, education and training for those providing care. Care providers, healthcare organizations, government and regulatory agencies share the responsibility for competent practice.
- Providers must seek
and incorporate evidenced-based practices that improve outcomes.
- Healthcare organizations
must promote the dissemination and assimilation of evidence-based science.
They must commit to patient safety through continuing education and site
- Government and regulatory
agencies must fund patient safety research. They must actively eliminate
every source of avoidable harm from the healthcare environment. Practices,
devices, therapies and practitioners who may present a risk must be: assessed,
identified, tracked and excluded from patient care.
patterns and work flow can cause
errors when physicians, nurses, and other health care workers are
too busy because of inadequate staffing or inadequate supervision . Leape
et al. demonstrated an association between practice environment and
patient safety. Numerous studies have demonstrated that a high patient-to-nurse
ratio is associated with negative patient outcomes.
- Technical failures include device/equipment failure and complications or failures of
implants or grafts. Thorough RCA can reveal issues that lead to failure. FMEA is a particularly useful method for developing educational and defect mediation programs.
- Inadequate policies and procedures indicate a lack of organizational commitment to patient safety. A culture of safety cannot be sustained without administrative leadership.
Which form of error analysis is prospective?