Factors Contributing to Errors
Patient Communication and Error Reduction
Introduction
Errors in treatment are a type of medical error which can often result in significant harm to patients. Some of the most common of errors are medication errors and surgical errors (Rodziewicz et al., 2024). Medication errors can involve incorrect dosages, the administration of the wrong drug, or failure to consider harmful drug interactions or allergies, all of which can lead to adverse drug events (Rodziewicz et al., 2024). Similarly, surgical errors, such as performing the wrong procedure or operating on the wrong site, can have life-threatening consequences. Intraoperative errors are estimated to be the primary issue in 75% of malpractice cases involving surgeons (Rodziewicz et al., 2024). These treatment errors not only affect patient safety but also demonstrate the need for better communication, verification, and oversight in healthcare settings.
Surgical Errors
Retained surgical instruments, also known as when tools or materials are left inside a patient’s body after surgery, is another dangerous type of surgical error (Santos & Jones, 2023). Retained objects can lead to serious infections, require additional surgeries, and significantly increase the risk of patient harm (Santos & Jones, 2023). Preventive strategies such as implementing standardized surgical counts and post-operative imaging protocols can help reduce the incidence of this error (Santos & Jones, 2023).
Factors Contributing to Errors
Many factors contribute to surgical errors, but one of the greatest is poor communication (Rodziewicz et al., 2024). Miscommunication can result in surgical teams operating on the wrong site or performing the incorrect procedure (Rodziewicz et al., 2024). Another factor that causes surgical errors is healthcare staff fatigue and burnout which can impair judgment, reduce attention to detail, and increase the likelihood of mistakes (Santos & Jones, 2023). Additionally, a lack of strict protocols regarding hygiene and disinfection protocols can lead to post-surgical infections, which are another form of preventable error. Surgical site infections are often the result of improper sterilization of instruments or the surgical environment. These infections not only prolong hospital stays but can also lead to conditions like sepsis, or even death (Rodziewicz et al., 2024).
Medication Errors
Medication errors are another important type of errors in treatment, and they may occur across various stages of the medication use process, including prescribing, documenting, transcribing, dispensing, administering, and monitoring (Tariq, 2024). However, nearly 50% of all medication errors happen during the prescribing or ordering stage, with a significant portion identified by nurses and pharmacists (Tariq, 2024). These errors can result in severe harm to patients, including death, and remain an important issue in the healthcare system (Tariq, 2024).
Factors contributing to medication errors include distractions, miscommunication, system failures and inadequate access to patient information (Tariq, 2024). Specific types of medication errors range from wrong dosage and incorrect timing to administering drugs to the wrong patient or via the wrong route (Tariq, 2024). Globally, medication related errors are responsible for 5% to 41.3% of all hospital admissions and 22% of readmissions after discharge (Tariq, 2024). Additionally, certain populations, such as elderly patients or those taking multiple medications, are especially vulnerable to these errors (Tariq, 2024). The risk of medication errors increases by 30% in patients prescribed five or more drugs and by 38% in those aged 75 and older (Tariq, 2024).
Preventive Strategies
Preventive strategies should focus heavily on improving communication, standardizing procedures, and making sure there is interprofessional collaboration. This includes medication reconciliation, clear prescription orders, and consistent monitoring practices (Tariq, 2024). The use of electronic health records, patient education, and elimination of handwritten prescriptions can also help reduce the likelihood of medication errors (Tariq, 2024).
Patient Communication and Error Reduction
However, errors in treatment may also be due to a lack of patient communication during the diagnostic and treatment process. In The Blissy Experience podcast, Dr. Beigi, founder of the Misdiagnosis Association & Research Institute (MARI), emphasizes the importance of patients actively participating in their own healthcare to avoid misdiagnoses and errors in treatment. He encourages individuals to “find the source of the error” and become more mindful about their bodies and symptoms, highlighting the need for patients to maintain thorough documentation and clearly communicate their concerns to their provider (Blissy, 2024). This proactive approach can support clinicians in making better informed decisions, ultimately reducing the risk of both diagnostic and treatment errors.
Conclusion
Overall, both surgical and medication errors represent significant errors in treatment that can cause significant harm to patients. While they may seem like very different types of errors, they are both usually caused by communication failures, systemic issues within the healthcare system, and human error. By implementing more safety protocols, promoting collaboration between different healthcare providers, and addressing systemic contributors, the number of these errors can be drastically reduced.
References
Blissy. (2024, August 9). Why your skin issue might be misdiagnosed! Dr. Beigi’s Insights | The Blissy Experience Ep. 10 [Video]. YouTube.
https://www.youtube.com/watch?v=yA7PpiNM600
Rodziewicz TL, Houseman B, Vaqar S, et al. Medical Error Reduction and Prevention. [Updated 2024 Feb 12]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK499956/
Santos, G., & Jones, M. W. (2023, May 29). Prevention of surgical errors. StatPearls – NCBI Bookshelf.
https://www.ncbi.nlm.nih.gov/books/NBK592394/
Provided and edited by the members of MARI Research, Error in Medicine Foundation, and MISMEDICINE Research Institute, including Kisha Patel, Bukky Alausa, and Dr. Pooya Beigi, MD. MSc.
