Healthcare News & Insights

Missing this critical step causes majority of medical errors

A new study sheds more light on how, and when, most medical errors happen.

A report, published in the Archives of Surgery, reviewed adverse events following surgical mishaps at 130 Veterans Administration hospitals between 2001 and 2006. The researchers found that most errors:

  • were caused by poor communication among the surgical team
  • happened very early in the procedure, and
  • weren’t caught when the surgical team did a final “time-out” to confirm info before starting the procedure.

The study’s authors recommend re-evaluating procedures to make sure vital info, such as identifying the right patient, the procedure being done and the location to be operated on are confirmed long before any part of the procedure is started.

Interventions that are done later in the process to catch errors are generally not working because they leave too much room for simple human error.

The researchers also noted that it’s possible to design a procedure that, if followed properly will catch virtually every mistake — the issue is making sure all the team members actually follow the procedure.

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