Types of Errors: Possible Causes and Potential Solutions

Communication with Health Care Providers

• Over the phone

  • Distractions and noise that interfere with the transactions

  • Heavy accents as well as other language barriers

  • Obscure terminology or big terms

  • Similar medications when spoken

  • Numbers that sound alike

• Handwritten communication

  • Poor handwriting

  • Names that look alike

  • Wrong name in the drop-down menu

  • Decimals either in the wrong spot or are unclear

  • Unclear abbreviations

  • Alert fatigue

• How to Compensate

  • Get rid of distractions

  • Try changing the lighting

  • Provide feedback and open communication with other healthcare professionals

  • Take advantage of barcoding

  • For sound-alikes, add accentuates on certain syllables

  • For verbal order, repeat it back to verify

Communication with Patients

• Common problems

  • Can’t comprehend

    • Accent

    • Terminology

  • Hearing or visual impairments: cannot understand written information

  • Not correctly identifying the patient

  • Patients not speaking up with questions

• How to fix

  • Allow the patients to paraphrase what you just told them

  • Give them a written copy of the information so they can refer to it later

  • Allow them to ask questions

  • Take advantage of your resources

General Strategies to Enhance Patient Safety

Reporting Errors

• To error is to be human: creating a safe environment where errors are nonpunitive is essential to have an open and honest atmosphere

• The purpose of reporting errors is not to get someone in trouble but to learn from it and possibly better the safety precautions

• The majority of errors are caused by the system and not the person

Organized Strategies to Minimize Errors

• Failure Mode and Effects Analysis and Root Cause Analysis are two ways to identify and prevent possible errors

  • FMEA identifies both sources and consequences of failures based on past events

  • RCA focuses on specific root causes of error

    • It asks why not how

• These systems cannot prevent 100% of errors

• They can only minimize how often and how severe they are

When Errors Occur

Initial Discovery

• Avoidance: denial that the error happened and refusal to help fix it

• Blame: “It was someone else’s fault they messed up”

• Rationalizing: it wasn’t that important: it is not a big deal

• Assuming someone else will catch their mistake

Initial Contact with Patient

• When meeting try to go somewhere private

• Explain what happened and the short-term consequence

• Tell them how the problem is being resolved

• Assure them they have not been forgotten about

Further Contact

• Once the patient has a clear idea that an error has occurred and how it is being resolved, you may want to provide additional insights into why it occurred.

• Some patients might want to know how it occurred and what steps you are going to implement to prevent future occurrences.

• Be honest and upfront with the patient about the long-term consequences of the error. They may be interested to learn how they will be compensated for their inconvenience or injury

• You should make sure that you do not rush through the experience and allow patients time to ask questions and express their feelings.

• This feedback will help you determine whether you need to conclude the interaction or continue to address the patient's remaining concerns.

• A sincere closing statement, such as "This rarely happens, but it happened with your prescription and I want to resolve it," may put the error in perspective.

Contacting Other Health Care Providers

• Be the one who controls the information

• Revealing errors to other providers is helpful for their quality assurance efforts as well.