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Healthcare-related errors: describe them in detail to understand them better

FEATURED REVIEW The realisation that a healthcare-related adverse effect was preventable is not enough to prevent similar errors. Error prevention also requires an understanding of the root causes, through in-depth analysis, preferably with everyone involved, including the patient.
Full review (5 pages) available for download by subscribers.

Abstract

  • By analysing and understanding errors in healthcare, we can overcome them and prevent their recurrence. The crucial first step in this detailed analysis is to confirm that the event was indeed an error, through methodical, objective characterisation.
     
  • A healthcare-related error is an unintentional act of omission or commission in healthcare delivery that culminates in the patient being at risk or experiencing an adverse effect.
     
  • By definition, errors are not deliberate. A healthcare error means that there was a discrepancy between what was done and what should have been done at one or more stages of the healthcare delivery process.
     
  • A healthcare-related error can be categorised objectively, for example by: the severity of its consequences, how close the error came to reaching the patient, and was eventually recovered, the likelihood of its occurrence, the stage in the healthcare process at which it occurred, and the failure mode.
     
  • Preventable adverse effects are often the result of a cascade of errors involving several health professionals.
     
  • The next step is to look for the root causes of the error, to develop strategies to prevent its recurrence.

©Prescrire 1 December 2018

"Healthcare-related errors: describe them in detail to understand them better" Prescrire Int 2018; 27 (199): 302-306. (Pdf, subscribers only)

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Download the full review.
Pdf, subscribers only

See also:

Reporting of errors by
healthcare professionals:
a source of information that is
useful in improving patient care
(October 2010)
Free