Analysis of Medical Errors: A Case Study

Background and Aim : Errors are defects in a pre-planned action which are made knowingly or through implementation of a wrong plan trying to reach the goal. Errors usually reflect a malfunctioning in the care system. The evidence suggests that a significant percentage of patients suffer from some complications while receiving the services. According to the studies, an unacceptable amount of medical harms and deaths can be avoided. The most common forms of errors in healthcare are medication errors. Given the different types of errors, it can be expected that, on average, at least one medication error a day occurs for each patient during hospitalization. Improving the patient safety culture and ethical performance are among the main components of providing the patients with the quality care, which requires professional commitment of the personnel. However, there are many hidden threats in government-run hospitals that affect the incidence of medical errors. The aim of the present study was to determine the frequency and types of medical errors in Taleghani Hospital affiliated to Shahid Beheshti University of Medical Sciences, in 2014. Materials and Methods : In this descriptive-analytical study, the voluntary error-reporting form was used for data collection in accordance with the standards of the patient-safety-friendly hospitals. This form comprised the patient profile, location of error specifications, the method of error notification, error reporter’s characteristics, error description, and the severity of the error, among which filling out the patient profile and error reporter’s characteristics was voluntary. The reliability and validity coefficients of the form were measured using CVR, CVI (0.72), and Cronbach's alpha (0.85). Of the 300 forms distributed, 162 error reporting forms were collected during a year, and the data for each form was entered into the software by determining their Identification code. Classification of preventable unwanted incidents was carried out based on the severity, type, and cause of the medical errors. In terms of severity, medical errors were divided into “near miss, incident events, accident events”, and “sentinel events”. SPSS version 19 software was used for the quantitative tests, and the comments by 10 experts were drawn upon for causal analysis of the data. Ethical Considerations : Completion of medical errors form report was carried out voluntarily, anonymously, without naming the error reporter, and the part where the error had occurred. In addition, the completed forms were collected from the wards and units, packaged in some sealed envelopes by a third “neutral” party, and sent to the person responsible for entering and collecting the data. Findings : Of the 300 voluntary error reporting forms distributed among clinical, polyclinic, and paraclinic units, 162 (52%) forms were completed and collected. The total number of errors reported was 158 errors, in 2014. Frequency of the errors consisted of medication errors (38.6%), errors in treatment, (36.1%), and errors in recording (25.3%), respectively. Events statistics was 33.5% for incident events, 15.2% for accident events, and 1.3% for sentinel events. Medication errors analysis based on the six principles of drug administration included wrong patient (32.14%), wrong drug (18.7%), wrong order (15.3%), wrong prescription (14.96%), wrong dosage (11.9%), and wrong time (7%). As for the theme of the errors, the most common type of error reported was for 20 wrong patients (32.78%), along with 11 wrong medicines (18.03%), 10 wrong prescription (16.39%), 9 wrong prescriptions (14.75%), 7 wrong dosage (11.47%), and 4 wrong time (6.55%). Conclusion : Despite informing the people and holding educational sessions, there still remain some barriers to reporting errors in the health system. Of the relevant factors, some are “fear of the rules and job threats, lack of awareness of the error occurred, fear of economic losses, fear of job prestige, and weaknesses in skills and knowledge of how to manage the errors”. Therefore, professional ethics education and error systematic management approaches are recommended. Given that in this study, the most common cause of the incidence of medication errors was the “wrong patient” due to lack of proper authentication of the similar patients to internal and external studies, to avoid errors in relation to Swiss cheese model- one of the most common theoretical models to study the root causes of errors, with the prominent feature of paying attention to hidden dimensions in the chain of error causes (30)- it is necessary that several measures be taken in management programs, the most important one of which is “human barrier” or “rechecking” that prevents the occurrence of the error in many cases. Providing such a barrier in the health system, however, requires a sufficient amount of efficient human resources. Proper identification of the patients, as one of the World Health Organization challenges for the patients’ safety, should be considered as a human factor to avoid errors. A second policy is developing the protocols, that is, forming some administrative barriers through developing some protocols and guidelines for identification of the patients, risky drugs, prescription of hypertonic solutions, etc. The third policy is education, especially in the field of professional ethics and monitoring of the implementation of the developed protocols and guidelines. The education and supervision must be carried out for all groups involved in the treatment of the patients, professors, students, and nurses. The fourth strategy is to create natural barriers, which comprises how to hospitalize the patients, how to store the medicines, and how to erect distance barriers. In addition, the last policy, physical barriers, includes barcodes, patient identification bracelets, and keeping the high-risk medications in special locked cabinets. It is, therefore, recommended that such barriers to the errors be used in a user-friendly way in order to protect the patients against medical errors. Moreover, since the most common types of medical errors are medication errors, it is also recommended that some techniques be used to improve the naming, labeling, and packaging of the drugs through effective partnerships with pharmaceutical companies.  Please cite this article as: Mohammad Alizadeh A, Davari F, Mansouri M, Mohammadnia M. Analysis of Medical Errors: A Case Study. Med Ethics J 2017; 10(38): 59-68.