The US Senate directed the Agency for Healthcare Research and Quality (AHRQ) to lead a national effort to improve patient safety and prevent medical errors. A number of projects were funded. The interim report (2003) to the Senate identified 8 common root causes of medical errors. These identified causes have served as guides in efforts to eliminate errors:
Eight common causes of medical errors
| 1. | Communication | These are the most common problems and | |
| problems | cause the widest variety of errors at all levels | ||
| of patient care. | |||
| 2. | Inadequate information | This includes problems that prevent timely | |
| flow | availability of information, such as laboratory | ||
| findings, and coordination of medication | |||
| orders. | |||
| 3. | Human problems | These include lack of knowledge, failure to | |
| follow procedures or standards of care, and | |||
| sub-optimal documentation/labeling. | |||
| 4. | Patient-related | These include improper patient identification, | |
| problems | failure to obtain informed consent, and | ||
| inadequate patient education. | |||
| 5. | Organizational transfer | This includes inadequacy in training or | |
| of knowledge | education for those providing care, including | ||
| procedures in place for an institution or unit. | |||
| 6. | Staffing pattern /work | This includes inadequate staffing and | |
| flow | supervision. | ||
| 7. | Technical failure | This includes equipment failure, poor | |
| equipment design, and inadequate instruction | |||
| in use of equipment. | |||
| 8. | Inadequate policies | These include failure in processes of care as | |
| and procedures | well as poorly documented, non-existing, or | ||
| inadequate procedures. |
Identification
The first goal that the Joint Commission outlines is a patient-related problem:
“Improve cytheofpatientaccuraidentificationrequires.” 2Thepatient guidelin
identifiers. Identifying the patient seems central to providing care, but failing to properly identify patients is the cause of many errors, sometimes resulting in the wrong patients having operations or receiving treatments or tests intended for someone else. One in-depth study used root-cause analysis to determine why the wrong patient, Joan Morris, underwent an invasive cardiac procedure intended for Jane Morrison. The study identified not one error, but 17 different and distinct errors, beginning with an original confusion in identification. Once this error had been made, the assumption, from one department to another, was that the woman was the correct patient—despite a different name, different
diagnosis, the patient’s statement that she knew n and didn’t wantnd nothesignedprocedure,consentform.Infact, shea was
convinced to sign a consent form—although clearly without “in because the test was totally unrelated to her condition. Repeatedly, Morris was referred to as “the patient”hanbyname. Evenorwhen“mystaff patient” noticed disparities, such as the difference from the laboratory schedule, they assumed there was an explanation.
There are a number of steps that staff must take in order to assure that patients are correctly identified. It is not sufficient to just glance at a wristband as one can look without actually seeing when procedures become routine.
Correctly identifying a patient
Always use two patient identifiers—usually name and birth date.
Ask the patient when possible, “What is your name?” date?”
Always check the wristband or another form of identification to verify identification, and read the name out loud.
Never assume that “knowing”identification patienortha right to ignore identification procedures.
Never trust other people to have correctly identified a patient.
Use names to identify patients, not others do this,.“DoSmithyou inmeanroomMr 86?”
Verify identification every single time for every single treatment or procedure.
Conduct – out”a“timebefore any —invasivefinalverification toproc confirm the right patient, the right treatment/procedure, the right site—using
active communication techniques.