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Chapter 4 - Sources of Medical Error

Published online by Cambridge University Press:  08 July 2022

John E. Kello
Affiliation:
Davidson College, North Carolina
Joseph A. Allen
Affiliation:
University of Utah
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Summary

Why are medical errors so common? We identify primary sources of medical error as system factors (both local workplace policies and procedures and broader societal and governmental requirements and technological advancements), teamwork factors, and individual factors. These three levels of influence interact and operate concurrently as healthcare providers are working with their patients. Each is a potential primary source of a medical error, but as in other HROs, error rarely has a single “cause.” Poorly designed systems can make it more difficult for teams to operate effectively and for individual healthcare providers to avoid mistakes. As much as all three levels of influence over safe practice are important, it ultimately comes down to the safe individual, the doctor who is “fit for duty.” They can operate effectively, contribute to team performance (help identify and correct the errors of others), and, as needed, lobby for improved policies and procedures. Again, the pandemic has added significant stress to the healthcare provider, calling for solutions at all three levels, addressing all three potential sources of error.

Type
Chapter
Information
The Burned Out Physician
Managing the Stress and Reducing the Errors
, pp. 67 - 80
Publisher: Cambridge University Press
Print publication year: 2022

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References

AHRQ. (2003). AHRQ’s patient safety initiative: building foundations, reducing risk. Retrieved March 8, 2021, from https://archive.ahrq.gov/research/findings/final-reports/pscongrpt/psini2.html.Google Scholar
Ellis, R., Hay-David, A. G. C., & Brennan, P. A. (2020). Operating during the COVID-19 pandemic: How to reduce medical error. British Journal of Oral and Maxillofacial Surgery, 58(5), 577580. doi: https://doi.org/10.1016/j.bjoms.2020.04.002.CrossRefGoogle ScholarPubMed
Hay-David, A. G. C., Herron, J. B. T., Gilling, P., Miller, A., & Brennan, P. A. (2020). Reducing medical error during a pandemic. British Journal of Oral and Maxillofacial Surgery, 58(5), 581584. doi: 10.1016/j.bjoms.2020.04.003.CrossRefGoogle ScholarPubMed
Hill, R. G. Jr., Sears, L. M., & Melanson, S. W. (2013). 4000 clicks: A productivity analysis of electronic medical records in a community hospital ED. The American Journal of Emergency Medicine, 31(11), 15911594.CrossRefGoogle Scholar
Kello, J. E. (2017). The machine will handle it … right? Automation doesn’t replace the need for vigilance. Industrial Safety & Hygiene News, 51(4), 16.Google Scholar
Morrison, M., Cope, V., & Murray, M. (2018). The underreporting of medication errors: A retrospective and comparative root cause analysis in an acute mental health unit over a 3-year period. International Journal of Mental Health Nursing, 27(6), 17191728. doi:10.1111/inm.12475.Google Scholar
Shaw, G. (2017). Most adverse events at hospitals still go unreported. The Hospitalist.org. Retrieved from www.the-hospitalist.org/hospitalist/article/125141/most-adverse-events-hospitals-still-go-unreported.Google Scholar

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