Some mistakes are straightforward. However, when it comes to a medical error, there may be moments, months or even years of conditions that set up the situation that leads to the mistake.
According to Always Culture, when health care professionals perform a root cause analysis of a medical mistake, they often uncover one of the following common issues.
The room for communication breakdowns in any given health care situation may be vast. The lapse could come between doctor and patient, hospital and clinic, physician and pharmacy, physician and lab or any other points along the communication chain.
When critical information is not available at the point of need, it can lead to a serious error. For example, if a patient goes to the emergency room of a hospital and a doctor does not have information about health conditions or prescriptions, he or she could make a fatal prescription error.
Sometimes, people fail to follow best practices, protocols, guidelines and procedures, and their failure triggers further errors. For example, a laboratory worker may mislabel a specimen, and the outcome could be a delayed or missed diagnosis that causes patient harm.
Understaffed facilities and lack of supervision create environments where even a big mistake can occur without detection until it is too late. Medical personnel who work long hours and must rush to keep up with their workload are more likely to make mistakes.
Organizations such as The Joint Commission as well as administrators of health care facilities work to eliminate the root causes and improve patient safety by developing best practices and standards and offering accreditations, performance improvement measures and resources.