The Agency for Healthcare Research and Quality through their Patient Safety Initiative (PSI) has identified common root causes of medical errors. They grouped factors that contribute to medical errors into eight categories.

(8 PSI categories with adapted nursing perspective )

• Communication problems were found to be the most common root cause of medical errors. Miscommunications can occur anytime information is transferred between patient and provider or between the multitude of entities that compose a modern healthcare system. Nurses are often the hub of patient data as it flows between departments. Multiple modes of electronic communication/documentation may be incorporated into nursing practice including text, audio, and video. Ideally, all patient care communication should be archived. Communications that are not text-based should follow a standard convention that includes: 1. (sender-message), 2. followed by a (receiver-message restatement), 3. followed by a sender-affirmation).
• Inadequate information flow:
  • Effective health information technology is timely, secure, transferable and accessible by authorized care providers at the point of care.
  • Point of Care Interface should incorporate: e-charting, continuous archived patient monitoring, automatic provider alert and decision guidance.
• Human problems relate to how standards of care, policies, or procedures are implemented. It is not enough to create and compile rules. Administrators must design systems that measurably produce compliance and reduce patient harm.
• Patient-related issues can include improper patient identification, incomplete patient assessment, failure to obtain consent, and inadequate patient education. Enlisting greater patient participation is currently a popular safety theme. While this may be a useful at the margins, it is unethical to shift the burden of self-defense on to the patient. The responsibility for assessment, treatment and outcome rests squarely upon the provider and healthcare fiduciaries.
• Organizational transfer of knowledge can include deficiencies in orientation or training, and lack of, or inconsistent, education and training for those providing care. Care providers, healthcare organizations, government and regulatory agencies share the responsibility for competent practice.
  • Providers must seek and incorporate evidenced-based practices that improve outcomes.
  • Healthcare organizations must promote the dissemination and assimilation of evidence-based science. They must commit to patient safety through continuing education and site specific competence.
  • Government and regulatory agencies must fund patient safety research. They must actively eliminate every source of avoidable harm from the healthcare environment. Practices, devices, therapies and practitioners who may present a risk must be: assessed, identified, tracked and excluded from patient care.
• Staffing patterns and work flow can cause errors when physicians, nurses, and other health care workers are too busy because of inadequate staffing or inadequate supervision . Leape et al. demonstrated an association between practice environment and patient safety. Numerous studies have demonstrated that a high patient-to-nurse ratio is associated with negative patient outcomes.
• Technical failures include device/equipment failure and complications or failures of implants or grafts. Thorough RCA can reveal issues that lead to failure. FMEA is a particularly useful method for developing educational and defect mediation programs.
• Inadequate policies and procedures indicate a lack of organizational commitment to patient safety. A culture of safety cannot be sustained without administrative leadership.

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