course material

1. Health care processes are increasingly being implicated in causing harm to
patients
Current Situation of Medical Errors Prepared by Asma Alshammari Alhanoof Alaniz Teflah
Ali Mai Alrweeli Munyfaa Aldhafeeri Norah AlmoteriIntroductionHealth care processes are
increasingly being implicated in causing harm to patients. Medical errors and adverse
events are primarily responsible for this harm. These errors, which may occur at every level
of the custom are both common and diverse in nature. Medical errors can occur anywhere
in the health care system in hospitals, clinics, surgery centers, doctors’ offices, nursing
homes, pharmacies, and patients’ homes and can have serious consequences. Errors can
involve medicines, surgery, diagnosis, equipment, or lab reports. Medical errors represent a
serious public health problem and pose a threat to patient safety. As health care institutions
establish “error” as a clinical and research priority, the answer to perhaps the most
fundamental question remains elusive: What is a medical error? To reduce medical error,
accurate measurements of its incidence, based on clear and consistent definitions, are
essential prerequisites for effective action.Despite a growing body of literature and research
on error in medicine, few studies have defined or measured “medical error” directly.
Instead, researchers have adopted surrogate measures of error that largely depend on
adverse patient outcomes or injury (i.e., are outcome-dependent).A lack of standardized
nomenclature and the use of multiple and overlapping definitions of medical error have
hindered data synthesis, analysis, collaborative work and evaluation of the impact of
changes in health care delivery. Medical error is defined as “failure of a planned action to be
completed as intended or use of a wrong plan to achieve an aim”. A medical error is a threat
to patient safety and has a negative effect on health as well.Definition of Medical
ErrorMedical error the term “error” has been variously defined. The Oxford Dictionary of
Current English (1998) defines it as “mistake” or the condition of being morally “wrong”.
Error has also been defined in a wider context as the failure of a planned action to be
completed as intended or the use of a wrong plan to achieve an aim (Reason, 1990).
Although the definition of “error” has its origins in behavioral psychology, the term is
appropriate for medical usage. Using Reason’s definition, IOM has tried to separate medical
error into two parts (Kohn et al., 2000): the first half of the definition constitutes “error of
execution” and the latter half, “error of planning.” In this context, two other related terms,
“adverse event” and “patient safety.” Bates et al. (1997) defined adverse events as injuries
that result from medical management, rather than from the underlying disease. Patient

2. safety, as defined by IOM, is freedom from accidental injury (Kohn et al., 2000). All three
terms, “medical error,” “adverse event,” and “patient safety” complement one another.Type
of medical error· Their two types of medical error according to moral and medical error
according to sit or eventMedical error According to moral: Error is a disorder of an
intentional act, and they distinguish between errors in planning an act and errors in its
execution. If a prior intention to reach a specified goal leads to action, and the action leads
to the goal, all is well. If the plan of action contains some flaw, that is a ‘mistake’. If a plan is a
good one but is badly executed, that is a failure of skill.This approach Mistakes can be
divided into· knowledge-based errors:Knowledge-based errors can be related to any type of
knowledge, general, specific, or expert. It is general knowledge that penicillin’s can cause
allergic reactions; knowing that your patient is allergic to penicillin is specific knowledge;
knowing that co-fluampicil contains penicillin’s is expert knowledge. Ignorance of any of
these facts could lead to a knowledge-based error.· rule-based errors. Failures of skill can be
divided intoRule-based errors can further be categorized asthe misapplication of a good
rule or the failure to apply a good rule;the application of a bad rule.· action-based errors
(‘slips’, including technical errors)An action-based error is defined as ‘the performance of
an action that was not what was intended. A slip of the pen, when a doctor intends to write
diltiazem but writes diazepam, is an example. Technical errors form a subset of action-
based errors. They have been defined as occurring when ‘an outcome fails to occur or the
wrong outcome is produced because the execution of an action was imperfect’ An example
is the addition to an infusion bottle of the wrong amount of drug· memory-based errors
(‘lapses’).Memory-based errors occur when something is forgotten; for example, giving
penicillin, knowing the patient to be allergic, but forgetting.How to prevent this type of
error:Knowledge-based errors can obviously be prevented by improving knowledge,e.g., by
ensuring that students are taught the basic principles of therapeutics and tested on their
practical application and that prescribers are kept up to date. Computerized decision-
support systems can also train prescribers to make fewer errorsMistakes that result from
applying bad rules, or misapplying or failing to apply good rules (rule-based errors), can be
prevented by improving rules.Training can help in preventing technical (action-based)
errors.Memory-based errors are the most difficult to prevent. They are best tackled by
putting in place systems that detect such errors and allow remedial actions. Check lists and
computerized systems can help.The second typey of medical error: According to sit or
events1/ medicationType of medication error· .Prescribing error· Omission error· .Wrong
time error· Unauthorized drug· Improper drug error· Wrong dose form error· Wrong dose
preparation error· Wrong administration technique errors· .Deteriorated drug errors·
Monitoring error· Compliance errorHow to prevention of medication error· Failure mode
and effects analysis· Legal requirements· Policies & procedures· Education and training·
Standardized order forms2/ surgicalTypes of surgical error· Failure to diagnose a
dangerous medical condition during surgery· Operating on the wrong part of a patient’s
body· Damaging healthy organs during surgery· Leaving instruments in a patient’s body
following surgery· Failure to prevent or fix complications during surgeryHow to prevent
surgical error· Mark the operation sits· Improving communication in operation room· Use
new technology in operation room3/ diagnostic error· Diagnostic· Error or delay in

3. diagnosis· Failure to employ indicated tests· Use of outcome ded tests or investigations·
Failure to act on results of monitoring or testing· Preventive· Failure to provide
prophylactic treatment· Inadequate monitoring or follow -up of treatment· Treatment·
Error in the performance of an operation , procedure , or therapy· Error in administering
the treatment· Error in the dose or method of using a drug· Avoidable delay in treatment or
in responding to an abnormal test· Inappropriate ( not indicated ) care·4/ infection
errorTypes of infection error like Viruses, bacteria, parasites, fungus, and prions are
different types of pathogens that cause infections.How to prevent infection:· Wash your
hands often, especially before and after preparing food, going to the bathroom, and after
other dirty tasks.1. Have a specially trained and dedicated infection control staff1. Regularly
educate all surgeons and staff on infection control measures1. Vaccinate and treat
personnel for exposure to infection at all times1. Implement computer-assisted decision
support and reminders that help doctors know when and how much antibiotic or other
medication to givenosocomial infection1. Staphylococcus aureus1. Escherichia coli1.
Candida1. MethicillinCauses by3. Urinary catheters (urinary tract infections)3. Surgical
procedures (surgical site infections)3. Central vinos catheters (blood sternum infection)3.
Mechanical ventilation (pneumonia)How to prevent nosocomial infections0. Frequent hand
hygiene is the most important preventative measure to limit the spread of pathogens.0.
Compliance with isolation precautions0. Proper use of personal protective equipment0.
Avoidance of unnecessary use of indwelling devices, and remove them as soon as
advisable.0. Practicing proper aseptic and/or sterile techniques during insertion and
maintenance of devices.4. Routine disinfection of surfaces, patient equipment, and medical
devices4. Appropriate waste management5/ blood transfusionblood transfusion mistakes
occur when1. incorrect blood is given to a patient. For instance, a blood sample may be
mislabeled.1. incorrect patient name may be marked on a blood sample,1. blood sample is
marked with the incorrect blood type (O-negative, etc.).1. too much blood given to patient1.
blood is stored at incorrect temperaturesHow prevent blood transfusion error1. training of
medical staff, including nurses and technicians.1. Mack sour that the correct blood group to
correctRULES AND PROGRAMS FOLLOWED IN THE HOSPITAL TO REDUCE MEDICAL
ERRORS IN SAUDI ARABIAThe Minister of Health, Dr. Abdullah bin Abdulaziz Al-Rabiah is
following with great interest the work of the technical committees that were recently
established within each health facility to detect the medical error as soon as it occurs
without the need for a complaint and linking the procedures for practicing the health
service according to a mechanism that is followed up electronically, which is known as the
“electronic dashboard” system. Dashboard in hospitals, which enhances the level of health
service and contributes to reducing medical errors.The Ministry of Health has set
procedures to reduce medical errors, including:1- Requiring all health personnel to register
professionally with the Saudi Commission for Health Specialties.2- Continuing medical
education for all health personnel, as a condition for re-registration.3- Requiring all health
personnel to train in clinical skills4- Implementing a program to monitor and measure
severe events.5- Implementing a performance measurement program.6- Implementation of
the clinical review program.7- Adopting treatment protocols and establishing the rules of
evidence-based medicine.8- Creation of quality committees in the ministry and directorates

4. of health affairs. 9- Implementing the performance indicators measurement program.10-
Creating committees to examine and approve the qualifications and experience of
doctors.11- Supporting infection control programs in hospitals and developing the skills of
workers.12- Strengthening health awareness programs inside and outside hospitals.13-
Developing an evaluation program for clinical and non-clinical departments in hospitals by
experts in the same field.14- Improving nursing skills and requesting nursing competencies
from developed countries.15- Introducing a bridging program for all technicians.16-
Introducing patient satisfaction measurement programs.17- Medical file repair program.18-
Establishment of medical performance review committees.Many medical errors are not
reported by healthcare professionals due to fear of retribution and may be concealed by
patients and their families in the sense that reporting them may be pointless. As long as
there is no system in place to report and address medical errors, these conditions will not
improve.The Saudi Center for Accreditation of Health Facilities is now developing a system
according to which it will receive and study the current cases of serious accidents that occur
in approved facilities, serious medical errors and serious accidents to be reported.The
Ministry of Health has identified the following events that need to be reported: 1-
Diagnostic or therapeutic procedure for the wrong patient 2- Performing surgery in the
wrong place 3- Serious damage caused by blood transfusion 4- Suicide in the hypnosis
department 5- Forgetting surgical tools and pads 6- Wrong medication that leads to death
or serious complications 7- Handing over a newborn to non-parents 8- Baby kidnapping 9-
Maternal mortality 10- An unexpected death 11- Unexpected loss of a party or function of a
member 12- Air embolism of a blood vesselStarting in January 2016, hospitals accredited by
the Saudi Center for Accreditation of Health Institutions must report all serious accidents by
filling in and submitting the Serious Accident Reporting Form on the electronic portal of the
Saudi Center for Accreditation of Health Facilities. This is within (5) working days from the
internal notification of the serious accident (the date on which the hospital administration
was notified of the accident). This must be followed by a Root Cause Analysis (RCA) and a
risk reduction action plan within (30) business days from the date of notification of the
serious accident. A root cause analysis is a formal process of investigations aimed at
identifying the root causes of adverse adverse events. The Saudi Center for Accreditation of
Health Facilities encouraged all health facilities as well as the beneficiaries From its
services, patients and reviewers are required to report serious medical errors to which they
were a party, and support everything that would achieve this. The policy followed by the
Saudi Center related to reporting serious medical errors states that we are a mandatory
report to all approved health facilities and a voluntary initiative for non-accredited health
facilities. And those that connect to the council by other means (informed means – the
patient – a relative)The most prominent benefits of reporting serious medical errors: 1.
Know the medical errors that occur in hospitals The various medical centers and how their
causes were, and what are the results of the radical analysis of them and the corrective plan
that was implemented, the Saudi Center for Accreditation of Health Facilities and all other
health facilities greatly helps in learning the lessons learned from those mistakes in order to
help avoid them in the future. 2. Reporting Medical Errors A practical guide provided by
health facilities to the public who benefit from their services as an indication of their Its

5. commitment to the required transparency in recognizing deficiencies when they occur. 3.
Reporting medical errors helps health facilities through the advisory services provided by
the Saudi Center for Accreditation of Health Institutions related to the fundamental analysis
of the error and the development of the corrective plan. 4. Reporting Medical Errors The
Saudi Center for Accreditation of Health Facilities assists in carrying out practical research
aimed at determining the rates and types of medical errors and methods of combating them,
and disseminating the results of those studies to all sectors of the health community in the
Kingdom. 5. Reporting medical errors is evidence of the approved health facilities’
commitment to the policy of maintenance and follow-up accreditation by the Saudi Center
for Accreditation of Health Facilities.‫ة‬ ‫ور‬ ‫ص‬‫وي‬ ‫ت‬ ‫ح‬ ‫ت‬ ‫لى‬ ‫ع‬ ‫ة‬ ‫د‬ ‫نض‬ ‫م‬ ‫م‬ ‫ت‬ ‫ء‬ ‫ا‬ ‫ش‬ ‫إن‬ ‫وصف‬ ‫ال‬
‫اقلت‬‫ئ‬‫ي‬‫ةرويًا‬ ‫وي‬ ‫ت‬ ‫ح‬ ‫ت‬ ‫لى‬ ‫ع‬ ‫ة‬ ‫د‬ ‫نض‬ ‫م‬ ‫م‬ ‫ت‬ ‫ء‬ ‫ا‬ ‫ش‬ ‫إن‬ ‫وصف‬ ‫ال‬ ‫ت‬
‫ئ‬‫ي‬‫ةرويًا‬COMMON CAUSES OF MEDICAL
ERRORS :Factors associated with health care professionals:· Lack of therapeutic training·
Inadequate drug knowledge and experience· Inadequate knowledge of the patient·
Inadequate perception of risk· Overworked or fatigued health care professionals· Physical
and emotional health issues· Poor communication between health care professional and
with patients are the most common causes of medical errors. Whether verbal or written,
these issues can arise in a medical practice or a healthcare system and can occur between a
physician, nurse, healthcare team member, or patient. Poor communication often results in
medical errorsFactors associated with patients· Patient characteristics (e.g., personality,
insufficient patient education and language barriers)· inappropriate patient identification·
failure to obtain consent· insufficient patient education.· Complexity of clinical case,
including multiple health conditions, polypharmacy and high-risk medications.Factors
associated with the work environment· Workload and time pressures· Distractions and
interruptions (by both primary care staff and patients)· Lack of standardized protocols and
procedures· Insufficient resources n Issues with the physical work environment (e.g.,
lighting, temperature and ventilation)· Inadequate staffing alone does not lead to medical
errors but can put healthcare workers in situations where they are more likely to make a
mistake.Factors associated with medicines· Naming of medicines· Labelling and
packagingFactors associated with tasks· Repetitive systems for ordering, processing and
authorization· Patient monitoring (dependent on practice, patient, other health care
settings, prescriber)Factors associated with computerized information systems· Difficult
processes for generating first prescriptions (e.g. drug pick lists, default dose regimens and
missed alerts)· Difficult processes for generating correct repeat prescriptions· Lack of
accuracy of patient records· Inadequate design that allows for human· Technical failures
can include complications or failures with medical devices, implants, grafts, or pieces of
equipment.Advice Help To Prevent Medical ErrorsMedical errors can occur anywhere in the
health care system: hospitals, clinics, surgery centers, doctors’ offices, nursing homes,
pharmacies, and patients’ homes. Errors can involve medicines, surgery, diagnosis,
equipment, or lab reports. These tips tell what you can do to get safer care.How to Reduce
or Prevent Medical Errors in health care system :Following steps are important in reducing
or preventing medical errors:· Make a center for patient safety within the agency for health
care research and quality:· Make national goals for patient safety· Follow the progress in the
meeting for the recognized goals· Form mandatory reporting systems regarding collection

6. and interpretation of medical mistakes· Make the standards and expectations for
improvement in safety high via the actions and support of oversight organizations· Make
safety systems inside the healthcare organizations via the use of safe practices at the
delivery level· Make an accurate patient’s identification· Increase the effectiveness of
communication among the patients and the providers· Timely reporting of important tests·
Label all the medications· Transfer accurately the medication information to nurses· Fulfill
the hand hygiene guidelines and thus decrease the risk of infection· Make a universal
agenda for preventing wrong site, wrong patient and wrong procedure and follow it .·
Complete the pre-procedure verification· Ensure the safe place for medication preparation·
Reduce interruptions during drug administration· Use calculator to calculate the exact dose·
Separate and label of drugs with similar names, colors or sounds· Check whether
medication is given to proper patient· Nursing education regarding calculation of dose·
Delivery of drugs from pharmacy to ward under supervision of staff nurse· Double checking
of medications via two separate nurses· Follow the rule of right i.e. right patient, right drug,
right dose, right route and right time· Head nurse must report the medication error when it
occurs· Nurses must have access to patient’s information· Increase the patient-nurse ratio
in each shift· Attendance of educational programs· Make and follow medication
administration policyAdvice Help To Prevent Medical Errors For patient :The best way you
can help to prevent errors is to be an active member of your health care team. That means
taking part in every decision about your health care. Research shows that patients who are
more involved with their care tend to get better results.1. Make sure that all of your doctors
know about every medicine you are taking.2. Bring all of your medicines and supplements
to your doctor visits.3. Make sure your doctor knows about any allergies and adverse
reactions you have had to medicines. When your doctor writes a prescription for you, make
sure you can read it.4. Ask for information about your medicines in terms you can
understand—both when your medicines are prescribed and when you get them:o What is
the medicine for?o How am I supposed to take it and for how long?o What side effects are
likely? What do I do if they occur?o Is this medicine safe to take with other medicines or
dietary supplements I am taking?o What food, drink, or activities should I avoid while
taking this medicine?5. When you pick up your medicine from the pharmacy, ask: Is this the
medicine that my doctor prescribed?6. If you have any questions about the directions on
your medicine labels, ask.7. Ask your pharmacist for the best device to measure your liquid
medicine.8. Ask for written information about the side effects your medicine could cause.1.
If you are in a hospital, consider asking all health care workers who will touch you whether
they have washed their hands.1. When you are being discharged from the hospital, ask your
doctor to explain the treatment plan you will follow at home.1. If you are having surgery,
make sure that you, your doctor, and your surgeon all agree on exactly what will be done.
Having surgery at the wrong site (for example, operating on the left knee instead of the
right) is rare. But even once is too often. The good news is that wrong-site surgery is 100
percent preventable. Surgeons are expected to sign their initials directly on the site to be
operated on before the surgery.1. If you have a choice, choose a hospital where many
patients have had the procedure or surgery you need. Research shows that patients tend to
have better results when they are treated in hospitals that have a great deal of experience

7. with their condition.1. Speak up if you have questions or concerns. You have a right to
question anyone who is involved with your care.1. Make sure that someone, such as your
primary care doctor, coordinates your care. This is especially important if you have many
health problems or are in the hospital.1. Make sure that all your doctors have your
important health information. Do not assume that everyone has all the information they
need.1. Ask a family member or friend to go to appointments with you. Even if you do not
need help now, you might need it later.1. Know that “more” is not always better. It is a good
idea to find out why a test or treatment is needed and how it can help you. You could be
better off without it.1. If you have a test, do not assume that no news is good news. Ask how
and when you will get the results.20- Learn about your condition and treatments by asking
your doctor and nurse and by using other reliable sources.Conclusion Medical errors are
one of the most important quality problems in health care today. All providers know
medical errors create a serious public health problem that poses a substantial threat to
patient safety. Part of the solution is to maintain a culture that works toward recognizing
safety challenges and implementing viable solutions rather than harboring a culture of
blame, shame, and punishment. Healthcare organizations need to establish a culture of
safety that focuses on system improvement by viewing medical errors as challenges that
must be overcome. All individuals on the healthcare team must play a role in making the
provision of healthcare safer for patients and healthcare workers. Often it is difficult to
recognize one’s mistake, but it is necessary to face the situation and try to learn from it so
that future errors can be prevented. Identifying the risk factors for medical errors is crucial
first step towards its prevention and is important goal of quality care assurance.