When it comes to medical mistakes that cause serious harm or death to patients, the most frequent question asked is: why? Why do these things happen? What is the main cause of medical errors made by doctors and other healthcare providers?
The Joint Commission set out to answer exactly that question. They reviewed over 14,000 instances of medical errors that resulted in severe harm or death. In looking at these cases, they reviewed the facility mandated Root Cause Analysis (RCA) which is a report that looks at the specific (often hidden or underlying) reasons behind the errors.
What Is A Root Cause Analysis (RCA) in Health Care?
The theory behind Root Cause Analysis (RCA) is that analyzing not just the events leading up to the mistake, but also the conditions surrounding the mistake, can help us understand them. When we understand why mistakes were made, we can better avoid them in the future.
In the world of health care, there are two types of errors: active and latent. Active errors occur immediately before the incident or injury, directly causing the harm. Latent errors, on the other hand, contributed to the incident or injury indirectly.
Often, events resulting in injury or death are preceded by both active and latent errors–the RCA’s job is to identify them.
The Main Causes of Medical Errors, According To The Study
So, what were the results of the Joint Commission’s review of the RCA’s? They identified several of the most common errors, including:
- Human errors. These are mistakes made by doctors, nurses and other hospital staff, for reasons including fatigue, stress, or multitasking.
- Communication errors. These are situations in which something was not communicated clearly or understood correctly, between members of hospital staff and patients and their families.
- Leadership errors. These occur when top level management does not have the appropriate policy or structure in place to prevent a certain error. For example, there may be insufficient training provided, an unsafe culture or environment, poor allocation of resources, etc.
- Assessment errors. These mistakes occur during the evaluation or assessment of a patient which result in improper care.
- Information management errors. These are errors involving the way medical records are kept, recorded, secured and made available.
- Physical environment errors. These mistakes have to do with the safety of the physical environment of the care facility (including construction issues, maintenance delays, equipment malfunctions, etc.)
- Care planning and continuum of care. These errors happen when the future care of a patient is not coordinated or communicated with all of the providers and/or family members involved.
- Medication use errors. These errors occur in the delivery of medication (as opposed to the prescription of medication) such as the medication storage, control, ordering and documentation systems.
- Operative care errors. These errors happen in plans for the operating room, including procedures and protocols, monitoring and equipment/supply usage.
What Does This Mean For Litigation?
Looking at the list above, it’s clear that many of these categories overlap. For example, let’s imagine a case where a patient was given the wrong dosage of a prescription. In this example, the doctor wrote the wrong amount and the patient ingested more than necessary. The doctor was at the end of his shift, fatigued. The hospital was understaffed and the pharmacist who fulfilled the prescription was inexperienced. That means this incident falls under at least three categories, human errors, leadership errors, and communication errors.
For those involved in the litigation of these matters, an understanding of the intricacies of these errors and first-hand experience in the field is crucial. This perspective gives the litigator a comprehensive look into all possible contributing factors and important details—things that someone who is unfamiliar with the field may miss.
Legal Medical Experts at Cardinal LifeCare Consulting
As experts in our field and providers who are familiar with legal proceedings concerning health care, we offer that unique perspective. From our vantage point, we can help identify underlying causes and concerns when it comes to preventable errors. With our life care planning services, we can also help ensure that a patient receives the appropriate amount of care after a mistake has been made. Law firms lean on our expertise to work toward a more conclusive and expeditious case for their clients. To learn more about the services we provide and the experience we offer, reach out to us at 724-487-0519 or Kelly@CardinalLifeCare.com
