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What are the principal causes of errors in health-care delivery?  What all are some of the key cultural, technical, and training solutions essential for error elimination?  What position has the JCAHO taken in response to these reports?

The principal causes of error in the health delivery system are poor systems and processes which result in delays, lack of standardization, poor teamwork and lack of focus on quality improvement.  Some key cultural, technical and training solutions that can help to prevent errors are creating a Culture of Safety within the organization, continuous education, proper use of information technology, and creating a system to monitor outcomes and processes.  JCAHO has taken a position the forces hospital to be ready for the next patient versus preparing for the next survey and established its national patient safety goals.

Principal causes of errors in health care delivery are as follows:

1.       Diagnostic:

a.       Failure or delay in diagnosis,

b.       Failure to order indicated tests,

c.       Failure to monitor patient or review testing results,

d.       Use of out moded tests or therapy

e.        

2.       Treatment and Monitoring:

a.       Error in performance of an operation,

b.       Error in administering treatment,

c.       Error in dose or method of administering a drug,

d.       Avoidable delay in treatment or in responding to abnormal test,

e.       Inappropriate care

f.          

3.       Preventive:

a.       Failure to provide prophylactic treatment,

b.       Inadequate following or monitoring of treatment

c.        

4.       Others :

a.       Failure of communication (either to appropriate physician, consult or staff),

b.       Equipment failure,

c.       Other system failure

Solutions for error elimination :

1.       Develop a Health Care system that achieves major gains in 6 areas to meet patient needs : These aims are built around the six core needs of health care including:  

a.       Safety

b.       Effective Health treatment,

c.       Patient centered,

d.       Timeliness,

e.       Efficiency,

f.         Equity.

Examples : include develop a nationwide reporting system with no fear of liability, establish national focus to create leadership tools and protocols to enhance safety.

To measurably improve patient safety, the JCAHO supports the creation of an effective medical/health care error reporting system, whether mandatory or voluntary, having the following characteristics:

1. Events to be reported to the system must be well-defined and, if a mandatory system, limited to serious adverse events.
2. Reports of serious adverse events must include the findings of the root cause analyses of these events.
3. All information reported to the system must be legally protected from disclosure (including by subpoena, discovery, introduction of evidence, testimony, or any other form of disclosure in connection with a civil or administrative proceeding under federal or state law or under the Freedom of Information Act).
4. The JCAHO and other health care oversight bodies having a legitimate "need to know" must have full and timely access to the data in the reporting system, on a health care organization-specific basis. This includes data about the adverse events, their root cause analyses, and the actions taken to reduce future risk. Disclosure of this information to accrediting bodies or other quality oversight bodies must not result in waiver of any protection against disclosure of the information provided by state or federal law.
5. The JCAHO must play a central role in the evaluation of root cause analyses for its accredited organizations, and in the dissemination of information to the health care field that facilitates learning about and implementing actions to improve patient safety.

References : JCHAO website www.jointcommission.org

The principal causes of errors are communication, management, physician leadership, training, organizational culture, staffing levels, availability of clinical information, compliance and coordination.

In my experience, retail pharmacy has become a paragon for error prevention and resolution.  Not only do pharmacists and techs have checks and balances in terms of powerful systems, but they also benefit from training geared toward accountability and responsibilty.  Customers learning about an error get an explanation, additional support and an apology.  They may not be happy, but they appreciate organization, communication and concern.  Small wonder pharmacy insurance is actually affordable.

Solutions: (1) cultural - safety first; (2) technical - need the info; need safeguards; and (3) training - educating staff is key.

JCAHO's position is that appropriate systems and processes will win the day with regard to error preventiion.  But wouldn't it be nice to if they had a metric for providers being hummane?