Root Cause of Medical Errors

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.

Leape 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 )

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Which form of error analysis is prospective?