Leaving equipment inside the patient after surgery. These are all nightmarish situations for a patient. But all of them are among the most common types of medical malpractice taking place in the United States today. Hospitals and clinics are riddled with pathogens, including the most potent superbugs, such as methicillin-resistant Staphylococcus aureus.
Neglect in medical care can result in a serious infection, which can form the basis of a negligence lawsuit. Surprisingly, according to a study, only 17% of healthcare workers routinely inform uninfected hospital patients about the risks of hospital infections. Young children and infants are equally prone to making common medical errors due to a lack of direct participation in decision-making and patient care. By mastering the application and methodology of RCA, health professionals can effectively promote changes and improvements in the healthcare environment, which translates into better patient care and a reduction of medical errors.
Root cause analysis (RCA) is a process for identifying the causal factors of a medical error that can cause a sentinel event. An adverse event in a healthcare setting can be attributed to a medical error and not meeting the threshold of malpractice or negligence. Therefore, identifying the root cause of a medical error can better determine the need for additional training and resources. Through a review of the data collected by the Joint Commission, the most common categories of clinical errors that cause patient death, and that can be prevented by analyzing the root causes, have been identified. Nurses can also make mistakes in the postoperative phase of treatment, such as administering incorrect medications, inadequate intervention that causes infection, or lack of adequate post-operative instructions that cause complications.
Hospitals can also standardize storage areas and avoid drug containers that look similar. When developing these interventions, the team must evaluate the list of root causes, consider their interrelationships, and explore risk reduction and process improvement strategies to prevent future errors at a systematic level. The interprofessional healthcare team plays an invaluable role in preventing medical errors; teamwork is crucial to identify strategies and solutions that reduce the burden of medical errors on the healthcare system. Surgery in the wrong place is one of the main causes of medical errors that can be mitigated by several pre-operative security checkpoints and has been the subject of a sentinel event alert by the Joint Commission.
Healthcare professionals should be familiar with the different types of medical errors to better understand the adverse effects that can occur. Other strategies include using color-coded intravenous lines, using standard concentrations of vasoactive agents, labeling syringes immediately after preparation, and capitalizing differences in drug labels with similar names. The following cases illustrate various types of medical errors, the process of analyzing the root causes by which the errors were identified, and how interventions were implemented in each situation to prevent similar errors in the future. Common types of medical errors include surgical errors, diagnostic errors, medication errors, equipment failures, patient falls, hospital-acquired infections, and communication failures.
Since most medical errors can be prevented, a comprehensive RCA can improve patient safety and allow healthcare organizations to serve as models for others.
