Medical Error Prevention and Reduction

By: Trisha Nagin

While it may be swept under the rug in the media, one of the leading causes of death in the United States is medical error, making this a detrimental public health problem[1]. In fact, for medical professionals, it is a challenge to find consistent causes of medical mistakes or a compatible solution to these problems.

To better understand medical errors, it is pertinent to understand the two main types of medical errors that occur. There are two major types of errors:

1. Errors of omission: These errors occur as a result of actions not taken.
2. Errors of the commission: These errors occur as a result of the wrong action taken [7].

There are many different types of errors of omission, however, some common errors include, the doctor’s failure to:

• Tell a patient about a vaccine or treatment that will save their life
• Thoroughly evaluate a patient
• Order the necessary imaging, blood work, or any diagnostic testing to reach a diagnosis
• Perform a necessary procedure or operate on a patient
• Prescribe drugs that are needed to improve the patient’s condition or to stabilize a patient
• Neglect the patient, and the description of problems [1]

There are many different types of errors of commission, however, the most common errors include, the doctor’s failure to:

• Carry out a surgical procedure correctly
• Giving patients the correct medication or dosage
• Going with the correct treatment options
• Giving the patient the correct diagnosis [1]

When these errors occur or are perceived it has the potential to lead to guilt, anxiety, anger, and depression, which manifests in the healthcare worker’s mind and can in turn lead to a loss of confidence in clinical settings. This loss of confidence in their work has other potential side effects and can increase the number of medical errors [2].

In fact, many medical institutions have rigid policies and are intolerant of errors, and will take action. Furthermore, the fear of punishment and loss of license, or the ability to continue practicing medicine, leaves doctors worried about medical errors and less likely to report them.

For this reason, medical institutions, governments, and healthcare providers must work together to remove the blame for patient outcomes while still holding the healthcare provider accountable for their actions.

There are methods of prevention that healthcare providers have opted to use and can help decrease the occurrence of medical errors, which include converting to electronic medical records (EHR systems), standard units of measure, weight-based dosing, employing the use of barcoding systems, and having essential medical staff on hand to assist with any confusions that may occur[6].

Furthermore, in efforts of avoiding prescribing errors, it is critical that pharmacists and healthcare providers review the dosage and patient before administering the treatment. In fact, Barcode medical administration is a prime example of new technology that helps in eliminating wrong patient dose errors. A study done by the Agency for Healthcare Research and Quality found that the use of Barcoding, at most pharmacies, reduces errors and decreases potential adverse drug effects[2].

The most Significant Preventative Technique for Medical Error Include:

• Adopting a checklist of what each provider needs to do
• Confirming the Identity of the Patient
• Double-checking dosages [4]
• Verbally conclude treatments/ surgeries
• Involving Pharmacists when prescribing medicine
• Standardize Equipment [3]

In addition to preventative techniques, healthcare workers and consultants must analyze the occurring errors, in efforts to mitigate them in the future.

Root Cause Analysis(RCA) is a technique that is used to identify the root cause of variation in a medical provider’s performance and is intended to discover the more hidden, but fundamental causes of medical error. In this type of analysis, the system and procedures used are analyzed more so in comparison to the provider to find the flaw within the steps rather than the person[2].

Another significant type of analysis that is performed is called Failure Mode Effect Analysis. This type of analysis identifies the causes and effects of medical failures and proves that although medical professionals are careful and diligent error still occurs. This type of analysis works with Quality Improvement, to correct the most common and likely types of error, build redundancies, and reduce common negligence[5].

In conclusion, although the best medical professionals are subject to mistakes, patient safety will increase as medical institutions show efforts in implementing action plans and analyses to reduce medical errors. Efforts such as the implementation of further error reporting and analysis, as well as government agencies and medical institutions working together, will mitigate medical errors in the future.

1. https://www.ncbi.nlm.nih.gov/books/NBK499956/
2. https://www.ncbi.nlm.nih.gov/books/NBK519065/
3. https://blog.cureatr.com/the-importance-of-medication-administration-5-ways-to-improve#:~:text=Implement%20medication%20safety%20technologies,or%20prevent%20medication%20administration%20errors.
4. https://hbr.org/2022/04/4-actions-to-reduce-medical-errors-in-u-s-hospitals
5. https://www.aamc.org/news-insights/20-years-patient-safety
6. https://www.cms.gov/Medicare/E-Health/EHealthRecords#:~:text=An%20Electronic%20Health%20Record%20
7. https://goldenlawoffice.com/medical-malpractice/what-is-a-medical-error-of-omission/

Trisha Nagin is a second year Computational and Systems Biology major at UCLA and is a THINQ 2022 intern.

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