Tackling the Problem of Medical Errors: How to Get to the Root Causes September 8, 2016.

Medical errors are one of the leading causes of death in the United States and a major cause of serious injuries. While patients can take certain steps to reduce the chances of a medical error, solving the root causes of the problem will require patients, the medical profession, and society as a whole to work together.

What Are the Root Causes of Medical Errors?

In one study by the Agency for Healthcare Research and Quality (AHRQ), the most common root causes of medical errors were identified and categorized.

Factors that contribute to medical errors were grouped into several overall categories:

• Communication problems were the most common root cause of medical errors. Any time information about a patient passes between two people or offices, miscommunications may occur.
• Inadequate information also resulted in a number of medical errors. This category included delayed information, insecure information, and information that was not accessible (for instance, because it was illegible).
• Deficiencies in education and training for staff members may cause harm if staff do not know how to provide proper care.
• Human problems with the implementation of standards of care, policies, and procedures also caused medical errors that led to harm.
• Staffing patterns and work flow increased the number of errors when staff were insufficient in number or were inadequately supervised.
• Patient-related issues, including improper identification, incomplete assessment, failure to get consent, and inadequate education, can also result in errors.
• Technical failure, including device or equipment failures, was also a significant source of error.
• Inadequate policies and procedures create an environment where the risk of error increases. Even when staff follows the rules perfectly, if the rules are insufficient, harm can result.

How Can Medical Errors Be Prevented?

Including patients in their care can address patient safety in many medical settings. However, researchers warn that the burden of defense against medical errors should not be placed on the patient.

Instead, researchers recommend that hospitals and medical providers focus on improvement in the eight categories above. They also strongly recommend a change in the cultural values and attitudes that surround the practice of medicine. In particular, studies have shown that when hospitals attempt to conceal errors or to punish those who point them out, the error rate is much higher than it is in hospitals that adopt a "no-fault" system of reporting errors.