Root Cause of Medical Error

Preventable medical error continues to occur at an alarming rate within the United States healthcare system. These mistakes result in intolerable, egregious consequences for the patient, families, and the care team. A root cause analysis can provide a beneficial resolution for healthcare professionals and patients to understand further and combat medical errors and prevent future occurrences (Singh, Patel & Boster. 2022)

Per the Institute of Medicine, a medical error is "the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim. Medical errors generally result from the improper execution of a plan or improper planning of a method of execution. Medical errors can also occur during preventative care measures, for example, if a provider overlooks a patient's allergy when administering medication.

Root cause analysis (RCA) is a retrospective process for identifying the causal factors underlying variations in performance. In the case of medical error, this variation in performance may result in a sentinel event. A standardized RCA process is mandated by the Joint Commission to identify the cause of medical errors and thus allow healthcare institutions to develop strategies to mitigate future errors. The emphasis of an RCA is placed heavily on system-level processes, not particular individuals' actions (Singh, Patel & Boster, 2022).

Failure to perform an RCA within 45 days of a sentinel event may result in the healthcare institution being placed on an 'accreditation watch,' which is public information. The framework used includes examining the systematic process, human factors, equipment malfunctions, environmental factors, uncontrollable external factors, organizational factors, staffing and qualifications, contingency plans, performance expectations, informational disruptions, communication, environmental risks, training, and technology. (Singh, Patel & Boster, 2022).

Failure Mode Effect Analysis (FMEA)
Failure mode effect analysis fosters safety and the prevention of accidents by prospectively identifying potential or real failures, causes, and effects. Failure mode effect analysis concludes errors will occur even if healthcare professionals are careful. Failure mode effect analysis engages in a continuous quality improvement process to assess and correct areas where an error is likely to occur. (Rodziewicz, Houseman & Hipskind 2022)

A few of the most common types of medical errors include: medication errors, errors related to anesthesia, hospital-acquired infections, missed or delayed diagnosis, avoidable delay in treatment, inadequate follow-up after treatment, inadequate monitoring after a procedure, failure to act on test results, failure to take proper precautions, and errors of medical technique (Tariq, Vashisht, Sinha, et al. 2022).

The AHRQ, through its Patient Safety Initiative, has identified common root causes of medical errors. They grouped factors that contribute to medical errors into eight categories.

(8 common causes with adapted nursing perspective )

• Communication problems were found to be the most common root cause of medical errors.
  Breakdowns in communication among providers are a common source of error that can result in adverse events, particularly at patient transition points. (AHRQ, 2021).
• Inadequate information flow:
  An integrated electronic health record is needed to improve accessibility of care information from within all the organisations, facilitating handovers between professionals and levels of care, and involving patients in the information flow (Kneck, Å 2019).
• Human problems relate to how standards of care, policies, or procedures are implemented. 
  • Nurses’ knowledge and attitudes were associated with their adherence to patient-safety principles .
  • Healthcare policy and practice need to be aligned with Patient Safety Principles to improve care and reduce patient harm (Vaismoradi M, 2020).
    
• 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. (AHRQ 2020)
• 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 regulate 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 workflow
  • Lower patient-to-nurse staffing ratios has been associated with significantly lower rates of hospital mortality, failure to rescue, cardiac arrest; hospital-acquired pneumonia, respiratory failure; patient falls (with and without injury); and pressure ulcers.
    
  • Higher numbers of patients per nurse has been strongly associated with the administration of the wrong medication or dose, pressure ulcers, and patient falls with injury.
    
  • If the 87 Illinois hospitals studied had a 4:1 Patient-to-nurse staffing ratio on medical-surgical units, more than 1595 Medicare patient deaths would have been avoided, and hospitals would have collectively saved over $117 million (Lasater et al., 2021).
  • Short-staffing increases patients’ risk of death by between 4% and 6%. This risk is higher within the first five days of admission (Eaton 2020).
• 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.

Additional Root Cause Tools

• The 5s Whys and Hows
  • 5 whys when looking for the cause: The 5 Whys is a simple but effective tool for getting to the root cause of a problem. The technique involves asking "why" five times to get to the underlying cause of a problem. For example, if a patient is given the wrong medication, you might ask "why" five times:
    1. "Why the patient was given the wrong medication."
    2. "Why the medication was not labeled correctly."
    3. "Why the medication was not checked by a pharmacist before it was given to the patient" ,and so on. By asking "why" five times, you can get to the root cause of the problem and identify steps that can be taken to prevent it from happening again.
  • 5 Hows, when looking for a solution.

 

• Fishbone diagram: A fishbone diagram, also known as a cause-and-effect diagram, is a visual tool that can be used to identify the different causes of a problem. The diagram is shaped like a fish, with the problem at the head of the fish and the different causes of the problem on the fins of the fish. The causes are then broken down into sub-causes, and so on. This tool can be helpful for identifying complex problems and for brainstorming solutions.

References

Agency for Healthcare Research and Quality (AHRQ) (2021). Approach to improving patient safety: Communication. Patient Safety Network. From https://psnet.ahrq.gov/perspective/approach-improving-patient-safety-communication

Agency for Healthcare Research and Quality (AHRQ) (n.d.). Efforts to Reduce Medical Errors: AHRQ's Response to Senate Committee on Appropriations Questions. Accessed 4/21/2023, from https://archive.ahrq.gov/research/findings/final-reports/pscongrpt/psini2.html

American Society for Quality (ASQ) (n.d.). FIVE WHYS AND FIVE HOWS. https://asq.org/quality-resources/five-whys

Eaton, D.(2020) The importance of safe patient staffing for nurses and the benefit for grads. Wolters Kluwer. (n.d.). https://www.wolterskluwer.com/en/expert-insights/importance-of-safe-patient-staffing-for-nurses-and-benefit-for-grads

Kneck, Å., Flink, M., Frykholm, O., Kirsebom, M., & Ekstedt, M. (2019). The Information Flow in a Healthcare Organisation with Integrated Units. International journal of integrated care, 19(3), 20. https://doi.org/10.5334/ijic.4192

Lasater, K. B., Aiken, L. H., Sloane, D., French, R., Martin, B., Alexander, M., & McHugh, M. D. (2021). Patient outcomes and cost savings associated with hospital safe nurse staffing legislation: an observational study. BMJ open, 11(12), e052899. https://doi.org/10.1136/bmjopen-2021-052899

Singh G, Patel RH, Boster J. Root Cause Analysis and Medical Error Prevention. [Updated 2023 May 30]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK570638/