Understand the vital approaches that you can work on to reduce medical errors and improve patient safety.
MD Experience Ido Zamberg is a board-certified physician and a Fellow at the Division of Experimental Medicine, McGill University Health Center, Montreal, Canada. About C8 Health's Editorial Process At C8 Health, our unwavering commitment is to provide you with trustworthy healthcare information...
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Editorial PolicyPublished July 4, 2024.
The impact of medical errors is staggering. Studies show they impact as many as 251,000 deaths annually and incur billions in healthcare spending. [1] These lapses in judgment can be detrimental to your organization
The good news is that you can prevent a significant portion of these mistakes. The result? Improved patient satisfaction, lower healthcare costs, and a stronger reputation for your facility. That's why we'll delve into effective prevention strategies.
» Want to reduce and prevent medical errors? Invest in a knowledge management system
3 Evidence-Based Strategies to Reduce Medical Errors
1. Improve the Work Environment
According to the Institute Of Medicine, hospitals must optimize their work environments, especially for nurses. [2] The findings suggest they make very few errors per hour worked, and overtime or longer shifts don't significantly increase mistakes unless they exceed 12 hours.
To reduce and prevent medical errors, the organization recommends limiting nursing shifts to 12 hours and total work weeks to 60 hours.
Beyond scheduling, a safe work environment is essential. Healthcare facilities should monitor patients, minimize interruptions, and reduce clerical tasks. They also need to target error-prone areas like medication administration and trainee supervision.
» Learn how to refine the onboarding process for new hires
2. Use Electronic Systems to Disseminate Knowledge
Hospitals and medical departments constantly create and update clinical resources to ensure that they meet the standards of care and reduce and prevent medical errors. Yet, this information is often siloed across departments, professions, and systems.
» Improve operational efficiency through strategic content dissemination
As a result, hospitals struggle to implement their best practices, leading to inconsistent patient care and burnout across clinical teams. But what if members of staff could access the guidelines they need and return to work within seconds?
C8 Health is the latest step in clinical resource management, trusted by leading hospitals worldwide, that addresses such problems. With the help of an AI assistant, staff can use natural language queries to simplify content search and retrieval.
Plus, the platform automatically detects and removes duplicate content to maintain a clean and accurate knowledge base.
3. Do a Root Cause and Failure Mode Analysis
Root cause analysis is a crucial process for identifying factors contributing to medical errors. The Joint Commission requires that all healthcare organizations conduct them after such events to reduce the chance of them happening again. [3]
For example, a patient on Warfarin experiences an internal bleed after unknowingly starting a daily dose of aspirin for headaches. The investigation uncovers that a provider didn't inform the patient about the interaction between these medications.
To solve this, a hospital would educate all staff on common interactions, particularly those involving high-risk drugs. It would also put in place an electronic alert system that checks flags identical issues.
» Explore the solution for effective medical education
On the other hand, a failure mode effect analysis is a proactive approach. It focuses on medical error prevention by continuously improving areas with specific scenarios where a mistake happened or is likely to happen. The goal is to create layers of protection that would stop a mistake in its tracks.
» Make your hospital's protocols accessible to everyone in real-time
Top 5 Most Common Causes of Medical Errors
1. Poor Communication
Optimal communication is crucial for reducing medical errors and improving patient safety. The focus should be on a respectful workplace that promotes this approach through risk management committees.
» Streamline collaboration with C8 Health's data-driven features.
For example, the Joint Commission's safety goals require a verbatim "read-back" procedure. [4] Let's say a nurse in the emergency room receives a critical blood test result for a patient having chest pain. The result shows a significantly elevated troponin level, indicating potential heart damage.
Here's what the process would look like:
- Read-Back: The nurse immediately calls the attending physician and verbally relays the critical result: "Dr. Jones, this is Nurse Smith from the ER. I have a critical test result for Mr. Lee. His troponin level is significantly elevated at 2.5 ng/mL."
- Verification: Dr. Jones acknowledges the information: "Thank you, Nurse Smith. I understand. Mr. Lee's troponin is elevated. Please get him on an ECG (electrocardiogram) right away and start him on aspirin according to the protocol."
- Documentation: She documents the entire interaction, including the read-back of the critical result and Dr. Jones' verbal confirmation and orders, in the patient's medical record.
Staff burnout can also disrupt communication during medical emergencies. C8 Health can prevent it by reducing administrative burden. It is a single place for all your organization's vetted guidelines that providers can quickly access on their phones.
2. Faulty Devices or Equipment
Technology can improve healthcare but may also cause harm. With many types of devices used worldwide, mistakes are inevitable due to design flaws, mishandling, user error, and malfunction.
» Explore the different types and uses of health information technology
Implanted devices and tube or catheter misconnections pose significant risks. [5] To improve patient safety and reduce chances of a medical error when administering them, healthcare institutions should:
- Develop protocols for equipment maintenance and training
- Educate clinicians on managing failures
- Use unique connectors
- Trace lines before connections
- Label high-risk catheters.
Additionally, there's a disconnect between technology and staff needs. Medical devices and software often don't receive enough input from healthcare professionals who use them daily, resulting in complex workflows and poor patient care.
» Explore the latest advancements and trends in medical technology
3. Acquired Infections
Healthcare-acquired infections are a serious issue, affecting 1 in 20 patients. [6] This increases complications, length of stay, and cost of care. For example, hand hygiene in intensive care units varies widely. [7] There are differences in compliance between occupations:
- Physicians: 61.2-77.1%
- Nurses: 80.2-90.9%
- Others: 61.3-82.4%
Make sure your staff follows safety protocols, as ignoring them makes them more detrimental in the long run.
» Learn how to increase compliance with best practices
4. Medication Errors
Medication errors can occur at various stages but are often preventable. According experts, common mistakes include overriding safeguards, confusing similar-sounding drugs, and using expired ones. [8]
To reduce mistakes, healthcare facilities can implement computerized provider order entry and barcoding systems. Barcode administration and electronic systems enhance safety by providing real-time information and identifying incorrect orders.
» Reduce medication errors through efficient knowledge management
5. Misdiagnosis
Diagnostic errors, defined as failures to establish accurate and timely explanations of health problems. About 12 million US patients experience them annually, with 33% resulting in injury. [9]
The five most frequently misdiagnosed conditions are malignancies, surgical complications, and neurological, cardiac, and urological issues. [10,11] These errors often stem from knowledge gaps, deficient bedside assessment, and clinical reasoning.
Other contributing factors include clinician fatigue, distraction, failure to consider differential diagnoses, and inadequate follow-up.
» Explore our big list of knowledge management statistics
Improving Care for Patient Safety
Understanding what constitutes a medical error, recognizing the factors that contribute to them, and effectively implementing protocols and procedures are essential steps toward enhancing patient safety.
Moving forward, it's crucial that healthcare institutions, policymakers, and individual practitioners alike embrace these strategies. Only through collective effort and dedication can we hope to create a future where medical errors are the exception rather than an accepted risk.
» Reduce and prevent medical errors through clinical resource management
