SUMMARY: A wide variety of external "systemic" factors facilitate individual physician error. Mistakes can usefully be identified as cognitive, skill-based or task-based. Personal vulnerabilities compound to increase the probability of serious error.
Clinical research continues to explore the diverse causes of medical error. Following is a useful classification of the elements that contribute to mistakes in hospital services: 1
Practical PointerFactors contributing to medical error in the hospital environment
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Patient factors that are common include an inability to give an accurate history, co-morbid medical conditions that distort the clinical presentation, and lifestyles that cause bias in the caregiver.
In outside systems and while accessing the in-patient service (pre-hospitalisation), errors arise in nursing homes, outpatients, community health services, and emergency medical services (EMS)
Identified errors in emergency department triage arise typically from patient load, staffing shortages, and inadequate resources. They commonly take the form of rule-based violations, insufficient triage rules, and errors in judgment.
The MedTeams Research Consortium cite teamwork failure as a primary or contributory factor in more than half the malpractice claims they reviewed involving death or major permanent impairment. 2 Failures of coordination, communication, interpersonal conflicts, turf wars, assignment of duties and responsibilities for which caregivers were not qualified featured prominently.
The individual service department environment ("microsystem") which is error-prone is typically stressed, overloaded, and malfunctioning.
Within the total hospital environment ("macrosystem") deficiencies in the laboratory, pharmacy, consultation services, and unavailability of specialty beds may trigger mistakes.
Hospital administration and third-party factors include budgetary constraints and ill-conceived policies and regulations that are rigidly adhered to.
In the community at large, homelessness, substance abuse, physical and sexual abuse, domestic violence, and gang violence increase the error-proneness of medical services provided for those caught in the web of social deprivation.
Against that background of systemic latent error, the physician characteristics that result in "sharp end" mistakes are being elucidated.
Mistakes can usefully be identified as cognitive, skill-based or task-based.
Caregiver failures can usefully be distinguished as cognitive, skill-set, and task-based errors. 1
Practical PointerTypes of physician error
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Both faulty assessment and inappropriate intervention are errors of planning. In major studies 2, diagnostic errors are often considered to have been negligent. Such assessment is however subject to hindsight bias.
Insufficient training or experience in interpreting investigation results and performing particular diagnostic and therapeutic procedures can be readily identified and corrected, given willingness and opportunity.
Failure of routine physician behaviours that are required for safe and effective patient care usually result from individual distraction or fatigue. Nevertheless, systemic factors such as work overload and failure of teamwork may also contribute.
Personal vulnerabilities compound to increase the probability of serious error.
Ever present, and more common than is usually acknowledged, is personal impairment by sleep deprivation, 3 burn-out and drug and alcohol abuse 4.
Practical PointerCommon interactive personal factors in physician error
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Family physicians who attributed cause to their own most memorable errors most commonly cited hurry, distraction, lack of knowledge, premature closure of the diagnostic process, and insufficiently aggressive patient management 5
Confirmation bias is a common form of premature closure: instead of critically evaluating all the evidence, the hurried physician looks only for features in the history, physical examination and investigations that confirm the first diagnosis that comes to mind. The immediate benefit is that the physician can avoid confronting inconsistencies by employing low-level decision rules, in response to emotions of which s/he is largely unaware 6 [].
Insufficient or excessive [] arousal or pleasure [] may interfere with cognitive processes 6 []. The mental tension of not knowing increases during the exploratory phase and may become critically high. To restore relaxation, the clinician may accept as a good diagnosis an early hypothesis which does not well fit the facts: examples of low-level and high-level decision rules []
Fear of medical malpractice litigation may significantly contribute to medical error in some clinical situations. 7
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