THINQ at UCLA
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THINQ at UCLA

Medical Errors: Detection and Future Prevention

By Darlene Lien

(Graphic by Dinah Wisenberg Brin on AAMCNews)

Despite emerging strategies to improve healthcare issues and policies, medical errors remain a growing phenomenon in the healthcare system. In some cases, medical errors could be harmless; however, in others, medical errors could have detrimental effects. Detecting and reducing such errors are essential to enhancing quality patient care. Yet one challenging aspect of identifying errors surrounds the very definition of a medical error — what exactly constitutes a medical error?

According to Wu et al., a useful definition of medical errors is:

“… a commission or omission with potentially negative consequences for the patient that would have been judged wrong by skilled and knowledgeable peers at the time it occurred, independent of whether there were any negative consequences.” [2]

While no clear-cut definition exists, merely recognizing and being mindful of medical errors could help reduce the threat that they could potentially pose to patient safety.

Causes of Medical Errors

Existing literature concerning errors in surgeries highlights key factors — such as human factors, interruptions, and staffing issues — that increase the risk of errors. Accordingly, a research study conducted by Fabri and Zayas-Castro reported that a majority of surgical complications were attributed to human error. It was found that of the 3.4% of major complications that occurred, human error was the root cause of 78.3% of such complications [7]. Furthermore, the human errors are broken down as follows: surgical technique errors (63.5%), judgment errors (29.6%), and incomplete understanding (22.7%) [7].

While research suggests that human error is a leading cause of medical errors, additional factors — organizational factors, situational factors, team factors, individual factors, task factors, and patient factors — play a role as well [3]. Organizational factors involve staffing and scheduling issues such as ensuring sufficient personnel and equipment. Situational factors generally relate to distractions or interruptions that occur as a patient is undergoing a medical procedure. Additionally, team factors essentially coalesce around group dynamics such as teamwork and communication; in other words, how team members collaborate with one another and facilitate a professional environment could impact surgical errors. Task factors are based on the clarity and accuracy of information and protocols. Lastly, individual factors operate in a similar fashion as to human errors; instead, individual factors include mental readiness, fatigue, and burnout [1]. Ultimately, as the list of medical errors continues, uncovering causes of errors brings the healthcare society closer to a solution for improving patient care and safety.

Prevention of Medical Errors

The onslaught of medical errors calls for safety interventions to be implemented, namely systematic changes that would mitigate errors.

One essential approach is to establish and ensure a medical working environment that embraces patient safety and quality care. Thus, rather than viewing errors with fear and shame, errors should be seen as opportunities for growth and improvement. Additionally, it is imperative that patient safety garners support and empowerment from management and the leadership of the organization. This could involve regular meetings between upper management and staff members to promote greater awareness of issues and ultimately develop potential solutions to improve patient safety. Other potential approaches include formal error training as well as an education system centered around patient safety.

Other times, medical errors necessitate systematic changes that give license to an improvement in reporting and measuring errors. These systematic changes hinge on the idea of a supportive work culture devoid of fear and shame. Research has shown that fewer incidences of medical errors are reported, generally due to fear and shame [4]. Increasing data collection on errors would simultaneously contribute to the learning system and enable more improvements to be generated.

In a study driven by the World Health Organization (WHO) and implemented by the World Alliance for Patient Safety, four primary areas for improvement included surgical site infection prevention, safe anesthesia, safe surgical teams, and measurement of surgical services [6]. As a result, a WHO Surgical Safety Checklist was created and provided guidelines in order to target the four areas. This entailed performing key safety procedures before induction of anesthesia, before skin incision, and before patient leaves the operating room. Thus, adopting a form of checklist for patient safety would provide a stepwise approach to medical procedures that fosters greater care and attentiveness to patients.

WHO Surgical Safety Checklist. Photo by the World Health Organization

However, it is also crucial that some form of evaluation be performed following the implementation of new procedures and interventions in order to assess their effectiveness. In the process of quality monitoring, reporting quantitative measures such as the number of patient injuries, infections, deaths, and other crucial fields are paramount; they provide a means for identifying trends in order to curtail the extent of medical errors [8].

While medical errors are essentially inevitable in health care, the implementation of key safety strategies could potentially improve patient outcomes to a significant degree. Moreover, reducing medical errors rests on the fundamental perception that errors are learning opportunities, not shaming occasions. After all, embracing a working environment that studies errors and works towards minimizing their occurrence only helps perpetuate quality patient care.

Darlene Lien is a second year Pre-Human Biology and Society major at UCLA and is a THINQ 2021–2022 clinical fellow.

Visit our website at thinq.med.ucla.edu and follow us on Facebook and Instagram @uclathinq!

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A coalition of UCLA students striving to improve the quality of the healthcare system.

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THINQ at UCLA

THINQ at UCLA

We are a coalition of students at UCLA striving to improve the quality of the healthcare system and promote social justice. Learn more at thinq.med.ucla.edu.

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