Medical Errors

Medication errors can occur anywhere in the medication administration process, ranging from ordering and documenting to dispensing and administering. However, most medication errors occur during prescribing or ordering, which accounts for around 50% of medication errors. The second most common time medication errors occur is during the administration stage. There are many types of medication errors, with some including (Tariq et al., 2024):

• Incorrect prescribing.
• Medication is not ordered, or the patient does not receive the ordered medication.
• Medication is administered at the wrong time (this is especially important for intravenous antibiotics or medications, like levothyroxine, that should be taken at a specific time to maximize absorption).
• Incorrect dose, preparation, or rate (for intravenous medications or pumps).
• Incorrect route.
• Incorrect patient.
• Failure to document a medication allergy.
• Contraindications to the medication.
• Using expired products.

Failure to monitor a medication’s potential effects is also a medication error. For example, oral antifungals can increase liver function values, which should be monitored before and during treatment. Failure to do so is a medication monitoring error (Tariq et al., 2024).

Human error accounts for a large portion of medical errors.  This includes both active and latent errors or failures. Active errors are those that directly involve a healthcare professional causing harm during patient care (Rodziewicz et al., 2024). For example, accidentally programming an intravenous pump incorrectly or prescribing a medication to a patient who is allergic to that medication. Active errors can be further divided into errors of planning or errors in execution. Some errors in planning are mistakes in rules or knowledge. Errors in execution are slips and lapses (Sameera et al., 2021).

Latent errors are intrinsic or organizational problems that cause patient harm. Sometimes, these can go unnoticed for long periods of time before actually causing patient harm. An example of a latent error is using faulty equipment or a healthcare organization using different types of equipment (like multiple types of intravenous pumps or ventilators) that can cause confusion on how to operate them (Rodziewicz et al., 2024).

Many individual factors of healthcare professionals can contribute to effective healthcare delivery and patient care. One study surveying more than 700 critical care nurses found that nurses with poor mental and physical well-being reported more medical errors than those nurses who were healthy (Melnyk et al., 2021). Some individual factors that may potentially contribute to medical errors include (Wiegmann et al., 2022):

• Mental state: The healthcare worker’s cognitive or emotional state, distractions, stress, or workload. For example, if a person is more stressed, they may feel pressured to hurry tasks and potentially make mistakes. In addition, professional burnout is a major contributing factor to medical errors. Several studies have linked physician burnout to an increased likelihood of significant medical errors (Li et al., 2023).
• Physical state: An individual’s physical well-being can also potentially lead to medical errors. Factors like physiological stress, fatigue, and sleep disruptions can impact patient care. Furthermore, several studies have identified nurse fatigue as a major contributing factor to medication administration errors. Fatigue leads to decreased cognition and lack of attention in nurses, which reduces patient safety (Bell et al., 2023).
• Patient Communication: Communication with the patient is another source of medical errors, especially medication errors. Factors like language barriers, medical jargon, and incomplete histories (confirming allergies, history, etc.) can poorly impact patient care and lead to errors (Tariq et al., 2024).

Healthcare team members must be able to communicate effectively and work as a team to provide quality patient care. There are some instances where team factors can influence patient care and possibly impact patient care, such as (Wiegmann et al., 2022):

• Coordination of care:Sometimes, improper patient coordination can lead to medical errors. For example, a patient is transferred from another facility, and the patient’s home medications are not verified with the prior facility. Another example is if a patient is transferred from outpatient urgent care, where an x-ray or another diagnostic test was already performed. The test and results were not communicated to the receiving facility (like the emergency room), so the receiving facility reorders the same test.
• Team Communication: Team communication is a large portion of quality patient care. If there is a communication breakdown, then this can potentially lead to medical errors. For example, if a patient becomes unresponsive and a team member starts cardiopulmonary resuscitation (CPR) and tells another team member to call for help (dialing 911 or calling a code). However, the other team member did not hear the request, so he just grabbed an oxygen tank when it was already available. This is a medical error and delays patient care since the rest of the medical team was not alerted promptly (Wiegmann et al., 2022).

Several organizational factors can affect healthcare delivery. Some of these factors include (Wiegmann et al., 2022):

• Culture: Organizational culture and decision-making can affect (increase or decrease) the risk of medical errors.
• Operational resources: Limited resources, like healthcare staff or equipment, can increase the risk of medical errors. Additionally, scheduling and staff assignments can impact patient care.
• Operational processes: Certain operational processes, like policies and procedures, can prevent medical errors. Conversely, these policies and procedures may be altered due to a previous medical error within the policy or procedure (Wiegmann et al., 2022). Lack of standardized protocols can potentially lead to medication errors (Tariq et al., 2024).
• Supervision: Lack of supervision, especially for those in training, can result in medical errors. Conversely, thorough professional guidance and engagement may reduce the likelihood of medical errors.

Many environmental factors can affect patient safety and potentially cause medical errors. Some of these include (Wiegmann et al., 2022):

• Equipment: Certain types and designs of medical equipment and devices can leave opportunities for medical errors to occur.
• Surrounding environment: A healthcare professional’s surroundings can also increase the likelihood of medical errors.  Factors can include noise, distractions, clutter, lighting, and room layout. For example, poor lighting when drawing up a medication, like insulin, could lead to a potential underdose or overdose if the nurse cannot correctly see the number labeled on the syringe.

Other factors can also increase the likelihood of medical errors. For example, older patients are more likely to have medication errors. Moreover, patients who are 65 and older are almost twice as likely to have a medication-related hospital admission than people who are younger than 65. Polypharmacy increases risk, as patients who take five or more medications are 30% more likely to experience a medication error. Multiple prescribers (providers who prescribe a medication) also increase the risk of medication errors, as well as patients with multiple comorbidities (Tariq et al., 2024).

Many healthcare organizations use the root cause analysis method to investigate and determine the underlying cause of the adverse or sentinel event. The method helps identify possible training, operational, and resource deficiencies that led to the near-miss or adverse event (Singh et al., 2024). Interestingly, many organizations use the Swiss Cheese Model to guide their root cause analysis since it identifies gaps or failures that led to the event or patient harm (Wiegmann et al., 2022). If submitted, some of the information in a root cause analysis is taken from the incident report.

Each health organization has a specific interprofessional team assigned to perform a root cause analysis on a reported event. Often, team members include individuals from risk management, quality improvement, clinical governance, clinical managers, key stakeholders, and other healthcare professionals. During a root cause analysis, the investigation attempts to discover any underlying deficiencies that caused the event. A root cause analysis often focuses on organizational or system-wide deficiencies and processes instead of the individual level. Interestingly, for organizations accredited by the Joint Commission, this organization provides a framework for healthcare systems to use when performing a root cause analysis. The framework poses questions to consider and investigate areas like communication, system processes, environmental factors, staffing, etc. After a root cause analysis, an action plan to resolve or correct the identified underlying deficiencies is discussed and performed (Singh et al., 2024).

Another method to identify medical errors is the failure mode effect analysis. This method seeks continuous quality improvement of processes to help identify and prevent medical errors. First, a process is selected, usually known as a problem or one to potentially cause problems. A team is assembled to analyze the process and identify potential or actual failures. After identifying these deficiencies, the team works on designing and implementing processes to prevent these from occurring. Last, the team evaluates the effectiveness of the implemented actions (American Society for Quality, 2024).

Unfortunately, there are instances where medical errors are not reported, especially in near-miss situations where a patient was not harmed. Several studies have been conducted to uncover some barriers to why medical errors are unreported. One study by Aljabari and Kadhim (2021) systematically reviewed 30 studies reporting barriers to medical errors by nurses, physicians, and other healthcare providers from 2000 to 2020. This study found that the most reported barrier (63%) to medical errors was fear of consequences, followed by a lack of feedback at 27% and work culture at 27% (Aljabari & Kadhim, 2021). Other studies have found that fear, lack of employee support, and staff training are potential barriers. Thus, it’s vital for healthcare team members to feel supported and have a positive workplace culture that avoids blaming staff but instead facilitates preventative measures, reporting, and further education (Asgarian et al., 2021).

As human error is a common cause of medical errors, there are some techniques to implement to help reduce these types of errors. For example, professionals in the operating room should avoid working long shifts and limit unnecessary conversations or noises that can serve as a distraction. Also, cognitive aids and tools should be used whenever possible. Examples of these include checklists, algorithms, mnemonics, and computerized prompts. Using checklists and algorithms in electronic health records can reduce human error (Sameera et al., 2021).

When considering diagnostic errors, the “rule of three” helps with human cognitive errors. The rule of three states that a healthcare provider should count to three and consider other possibilities and alternatives. This method helps the provider pause their thought and reasoning process. Another alternative to using the rule of three is to consider at least three alternatives when making a diagnosis and treatment (Sameera et al., 2021).

Healthcare organizations should have an incident reporting system to aid with recording medical errors and sentinel events. Again, this reporting system helps identify and survey medical errors. Simply having an incident reporting system can help identify possible deficiencies in healthcare systems and lead to organizational change and prevention measures.

Most healthcare organizations have a risk management department that helps with safety monitoring and reporting. This department is largely responsible for pinpointing risks early and performing ongoing risk assessments. A risk assessment helps identify possible medical errors, estimates their risk, and evaluates the potential implications of medical errors. The risk management department is also typically involved in reviewing incident reports and performing root cause analysis to determine deficiencies in patient care that lead to medical errors. A health system’s risk management is also involved in policy and procedure creation and management.

This area of expertise uses many tools to assess risk. Some of these include:

• Performing a risk analysis.
• Determining which risk assessment tools to implement into patient practices.
• Cost-benefit analysis of risk assessment tools and implementation (Ferdosi et al., 2020).

Furthermore, risk managers use several techniques in their roles, which include:

• Avoidance: Avoidance, also known as the forcing function, eliminates the potential for loss (i.e., an error). Avoidance entails designing policies, processes, or even equipment to virtually prevent an adverse event from occurring. An example is not allowing a nurse to override the withdrawal of certain medications (e.g., rocuronium—paralytic) from a medication dispensing machine. Another example is only stocking one type of supply or certain supplies in a unit.
• Retention:In some cases, keeping a portion of the risk or the entire risk is more cost-effective for the health system. For example, a health organization may attempt to move to one manufacturer and a certain concentration of a life-saving medication to reduce errors. However, sometimes, the supply chain may be interrupted, and this medication may become unavailable from a single manufacturer. Instead, risk management may choose to have another supplier of this medication since it is a lifesaving medication. Thus, the health system is absorbing some risk since two medications can have different concentrations depending on the manufacturer, which potentially leaves an opportunity for a medical error to occur.
• Spreading: Some risk management departments may choose to spread the risk of loss. For example, extra equipment may be stored in a separate facility to spread the risk of loss. A hospital may store extra IV pumps and oxygen tanks in a nearby outpatient facility or administration building so that if a fire were to occur inside the hospital or a mass causality event occurred, the hospital would have backup supplies readily available.
• Loss Prevention and Reduction: Health systems and risk managers attempt to minimize the severity and frequency of risk. Loss prevention helps to reduce the likelihood of loss but does not reduce its severity. An example is a medication dispensing machine with a lockout mechanism for when a pain medication is withdrawn and administered to a patient; the nurse cannot withdraw the medication again until the preprogrammed amount of time has passed. This is also common with scheduled medications within the patient’s record. Some health facilities do not allow nurses to withdraw or administer medications with the electronic health record unless it is within the patient’s scheduled time window. Loss reduction entails reducing the severity of the damage. A common example is the implementation of standardized protocols and procedures, like procedural checklists.
• Transfer: In many scenarios, health systems and risk managers choose to transfer or negotiate a portion of risk, usually by a contract. An example is insurance companies and contracts with healthcare providers and facilities. Health systems have large medical liability and property insurance policies to help transfer some of the risk. For instance, if there is a medical malpractice lawsuit against a health facility, the healthcare company will likely have a liability insurance policy that helps transfer a portion of its risk to the insurance company (California State University, Fullerton, 2022).

Healthcare employee training and competency is a crucial component of preventing medical errors. Many professionals might be unaware of evidence-based safety practices and strategies to reduce medical errors without education. Therefore, many healthcare accreditation organizations require health systems to provide initial and annual safety training to all their employees. Promoting system-wide skill development and ongoing competency can also minimize the risk of medical errors. Staying current with best practices through continuing medical education and reviewing recent research can reduce medical errors. Therefore, health systems should consider and offer their employees educational and professional development opportunities (Gemmete, 2024).

Furthermore, many healthcare professionals are unaware of what constitutes a medical error. Therefore, training and competency in medical error recognition are essential, as well as training regarding incident reporting (Tariq et al., 2024).

Some medical errors come in the form of billing and coding practices and practices, which can result in further downstream consequences, like claim denials, penalties, fraudulent claims, underpayment, and overbilling. Implementing medical coders and reviewers, who are individuals trained in medical billing, can help reduce the risk of billing issues and errors. In addition, this is where proper training play of these medical coders and providers plays a vital role in medical error prevention. Proper billing and coding help reduce legal and financial risk and potential penalties and fines.

Patient Simulation Model

Virtual Reality Simulation-Based Training

Using artificial intelligence (AI) in a healthcare setting is another way to promote patient safety and decrease the likelihood of medical errors. Some health systems’ electronic medical records have AI embedded to assist with identifying potential patient safety issues. Some AI systems can assist with patient monitoring, like minimizing unnecessary alarms, monitoring pulse and blood pressure, and analyzing false cardiac arrhythmias. While others can identify incidents, review patient feedback, and extract valuable information from safety reports. Many of these avenues are a way to prevent and reduce medical errors. However, further research is still needed on efficacy and training and its true impact on patient safety (Choudhury & Asan, 2020). Regardless, many health systems have adopted artificial intelligence into their organizational practices to identify potential medical errors and safety concerns.

Changing the workplace culture of incident reporting is key to error prevention. Health organizations should instill a safety culture and discuss incident reporting and its benefits to the health system. Instead of discussing errors at an individual level and their consequences, they should discuss how errors are a system-wide issue and can lead to changes in processes. Professionals should feel empowered by reporting possible incidents or adverse events that occur (Tariq et al., 2024).

Furthermore, health organizations should instill a culture of transparency, non-punitive measures, and accountability. Through these actions, organizations and team members can learn from their mistakes and prevent future or further harm. This, in turn, promotes a culture of safety and data-driven preventative measures (Zangaro et al., 2023). Also, many health systems are shifting from a pay-for-performance model to a value-based model to promote quality and safety practices(Sameera et al., 2021).

In addition, organizations should support a company culture of effective teamwork. They should strengthen teamwork by providing adequate resources, especially communication and staffing. Providing team-building and development opportunities can potentially reduce the rate of staff turnover, thus promoting proper staffing levels and improving patient safety (Zangaro et al., 2023).

Healthcare professional burnout is a major factor contributing to medical errors, and addressing burnout is of utmost importance. Therefore, employers should look for areas of improvement within their organization. Factors such as inadequate staffing levels and staff engagement in safety can negatively impact employees and contribute to burnout. Instead, health systems should promote staff engagement in safety concerns and resolutions and have adequate resources and staff. In turn, employees are more likely to support one another, collaborate, communicate, and gain knowledge of safety protocols (Zangaro et al., 2023). Additionally, health employers should support available mental health resources, invest in health prevention, and promote a culture of inclusion(Office of the General Surgeon, 2024).

A portion of addressing burnout also falls on the individuals themselves. Health professionals should know their physical, mental, and spiritual well-being. Moreover, they should be aware of the signs of burnout (Office of the General Surgeon, 2024), some of which include:

• Depersonalization (feeling disconnected)
• Emotional exhaustion
• Low sense of accomplishment
• Emptiness
• Withdrawal
• Neglecting personal needs
• Depression
• Anxiety

Other physical symptoms, like fatigue, headaches, irritability, and sleep problems, may develop (De Hert, 2020). Health professionals should instill self-care practices to prevent burnout, including promoting physical and mental health. They should seek mental health counseling and address any underlying mental well-being problems. Stress management and participating in small group discussions with others experiencing similar symptoms can be helpful (Razai et al., 2023).

There are several ways to reduce and prevent surgical errors from occurring. Simply adopting and completing standardized checklists before, during, and after surgery can help reduce errors. In addition, performing a surgical time-out (pause), including all team members, before any procedure helps ensure the correct patient, surgery, and surgery site. If the patient is undergoing multiple surgeries or has multiple surgeons, a time-out is performed for each. Marking the patient’s surgical site, especially for surgeries involving laterality (right or left), before surgery is also an error prevention method. Operating rooms also use measures like counting instruments before and after surgery to reduce surgical errors and foreign body retention (Rodziewicz et al., 2024).

Several strategies exist to prevent diagnostic errors. Tools like diagnostic algorithms, checklists, and differential diagnosis considerations can help reduce diagnostic errors. The provider should be encouraged to think critically about possible differential diagnoses and should foster interdisciplinary communication and collaboration. Additionally, simulation-based training and performance feedback can decrease the likelihood of diagnostic errors (Rodziewicz et al., 2024).

There are many ways to prevent medication errors from occurring. Some of these include (Sameera et al., 2021):

• Barcode scanning:The patient’s armband and medication barcode must be scanned before administering a medication. The computer system displays the correct information and can alert the health provider if something is incorrect.
• Standardized arrangement: Medications are arranged in a standardized fashion in certain areas, like the operating room, crash cards, or medication rooms, which helps to prevent medication errors. This is helpful during emergencies so the provider can quickly recall where a medication is typically located.
• Standardized medication dosages: Having standardized medication dosages and concentrations available is helpful, especially during emergencies. In an outpatient setting, emergency medications available in autoinjectors, like epinephrine, can also prevent medication errors. Prefilled syringes and infusion bags are also helpful.
• Tall man lettering:Medications that sound alike or look alike use tall man lettering and bolding to help readily identify the medication. Examples are DOPamine versus DOBUTamine, hydrALAZINE versus hydrOXYzine, and traZODone versus traMADol (Sameera et al., 2021).
• Computerized Physician Order Entry (CPOE) systems: Interestingly, CPOE systems are the most effective strategy for preventing medication errors. This system allows for real-time prescribing, and many CPOEs check for allergies, medication interactions, and duplicate medications and alert the prescribing provider.
• Automated Medication Dispensing Machines: Many hospitals and large health systems implement medication dispensing machines. The nurse selects the patient and medication from the patient’s list of ordered medications. The machine dispenses the medication and also has certain lockout parameters.
• Medication Reconciliation: Complete medication reconciliation, especially for new patients or during transitions in care, is vital to preventing medication errors. Documenting the dosage, route, and frequency of the prescribed medications is key, as is entering any over-the-counter medications or supplements the patient is taking.
• Optimize Workflow:Measures to optimize health professional workflow should also be taken. This is a strategy and individual can use to prevent error. Minimizing interruptions and having a “distraction-free zone” are helpful ways to optimize workflow, especially during the preparation and administration steps of the medication administration process.
• Limit Handwritten Prescriptions: Prescribing providers should limit the use of handwritten prescriptions whenever possible. If a prescription needs to be handwritten, the prescribing provider should approach it with caution, write the exact dosage, limit the use of abbreviations, follow decimal point rules, and avoid using trailing zeros.
• Limit Verbal Orders: Prescribing providers should limit the use of verbal orders whenever possible since this is where communication and transcription errors may occur. If necessary, the person receiving the orders should repeat the order to the prescriber to confirm accuracy (Tariq et al., 2024).
• Clinical Decision Support Systems: This support system is a tool for error prevention. Examples are computerized alerts, reminders, and prefilled order sets within an electronic health record.
• Follow the Medication Rights: When administering a medication, the nurse or other health professional should use the medication rights, such as the right patient, dose, time, route, etc.
• Use Smart Infusion Pumps: When administering intravenous medications, an infusion pump should be used instead of manually hanging an IV bag. Infusion pumps provide lockouts for certain medications and rates, which can help reduce errors.
• Provide Patient Education: Whenever possible, educate patients about their medications. Include information such as the medication’s name, why they are taking it, side effects, and any special administration instructions (Patient Safety Network, 2019).

Equipment malfunctions are not limited to an inpatient setting but can also occur in an outpatient setting or a patient’s home. Design flaws and user errors are common causes of medical errors. Design flaws and device/equipment malfunctions should be reported to the manufacturer, as they can gather information to change equipment design, provide better instructions, or issue a recall.

In addition, health professionals operating the equipment must receive proper training about equipment use, safety measures, and protocols. Professionals should inspect the equipment regularly, and lines should be traced back to their connection points for intravenous equipment. Patients who have medical devices at home should receive proper equipment training and check their devices' function frequently (Rodziewicz et al., 2024).

Alarm parameters and functioning should be frequently checked on medical devices and equipment. Typically, health systems have policies and protocols for how often alarms and equipment should be checked and receive scheduled maintenance (Rodziewicz et al., 2024). Furthermore, The Joint Commission’s 2024 Hospital National Patient Safety Goals provide recommendations on alarm safety as improving the safety of alarm systems is a safety goal. Some instances where alarm safety should be considered are if alarms are off, inaudible, or diagnosed. Narrow or broad alarm parameters can also be a safety concern. Suggested strategies to improve alarm safety include:

• Identify alarm and monitoring systems that should be managed. Health organizations should seek input from multiple sources, such as employees, stakeholders, and managers.
• Discuss whether the identified alarm system should have a noise or alert. This is a valuable step to reduce alarm fatigue.
• Ensure the implementation of certain policies and procedures surrounding alarm and patient monitoring systems. These policies, especially if changed, should be reviewed with managers and team members affected by these policy changes.
• Ensure alarm parameters monitoring frequency and policies/provides are communicated to all team members. For example, suppose a policy is created for cardiac rhythm alarms and parameters to be checked at the start of the shift of the healthcare professionals; this must be communicated to the team members, managers, nurses, etc. (The Joint Commission, 2024b).

Many hospital-acquired infections (HAIs) result from improper hand hygiene and failure to wear proper personal protective equipment (PPE). Thus, common HAIs include catheter-associated urinary tract infections (CAUTIs), central-line associated bloodstream infections (CLABSIs), and other infections involving aseptic or sterile techniques. To combat HAIs, health organizations should consider changing employee hand hygiene behaviors through hand hygiene campaigns and regularly auditing hygiene practices. Other prevention strategies are minimizing the duration of indwelling catheter use as much as possible, antibiotic stewardship programs, and following certain infection measures (wearing PPE, frequently assessing wounds, and using chlorhexidine to cleanse catheter sites) (Rodziewicz et al., 2024).

Many healthcare systems implement fall prevention strategies within their facilities to aid patient safety. Using assessment tools, like the Morse fall scale, can reduce the risk of patient falls through early identification of patients at increased risk (Rodziewicz et al., 2024). Hospital systems may also implement universal fall prevention measures for every patient, such as wearing non-slip socks, door signage, patient wristbands, and patient and family education. Other strategies may include setting bed and chair alarms, implementing one-on-one sitters, and intentional patient rounding. Environmental modifications can also potentially help reduce falls, like bright lighting, placing the call light within patient reach, using special rooms for patients at high risk (i.e., near the nurses’ station), and moving the bed to the lowest position. All healthcare staff members should receive training on fall prevention and remain diligent with fall prevention measures (LeLaurin  & Shorr, 2019).

Patient and family education is a key component of fall prevention in an inpatient setting, and it is just as important in outpatient and home settings. Health professionals should discuss best practices in all settings to reduce the likelihood of falls. These may include using assistive devices for ambulating, reviewing home medications, and wearing the correct shoes. Reducing clutter in the home, improving lighting, and removing rugs can decrease the chances of falling at home.

There are many strategies to reduce the chances of communication errors. Some of these include:

• Using checklists: Implementing the use of checklists can help improve team communication and serve as a guide.
• Time out: This method is commonly used in the operating room before surgery. The team pauses before surgery and confirms the patient, procedure, and site before beginning the procedure (Sameera et al., 2021).
• SBAR: SBAR (situation, background, assessment, recommendation) is a common communication tool in many healthcare settings. The situation is where the healthcare professional introduces themselves and then explains the current problem or situation to the patient. Next, a brief patient background is provided, typically including the patient’s history, symptoms, and test results. Then, an assessment is provided, which provides objective data and a description of what the communicator thinks the problem may be. Last, the communicator provides their initial recommendations and receives orders or next steps in care. They repeat back the orders to confirm accuracy (Agency for Healthcare Research and Quality, 2019).
• Call-back or repeat-back: As the name implies, this method simply repeats information to ensure accuracy. For example, a nurse receives verbal orders from a provider and then repeats the orders to confirm.
• Alert phrases:Alert phrases that convey the seriousness or urgency of the situation can also be used as a communication technique. Examples are “this situation is serious,” “high alert,” or “code blue” (Sameera et al., 2021).
• PACE:PACE (Probe, alert, challenge, escalate/emergency) is another communication tool used to express concerns, especially when speaking to superiors. At first, the individual can probe their concern to express feelings and raise awareness about the situation. Then, if this fails, they can be alerted by repeating the concern. Next, to challenge means to confront the person. Last, the person may need to escalate their concern by interrupting the other person, saying stop, or possibly taking over the task. When using this communication tool, the receiver must acknowledge the other’s concern to be considered effective (Sameera et al., 2021).

Another way to reduce the chances of a medical error is to document information within the patient’s medical record properly. The Nurses Service Organization (2024) offers a valuable list of do’s and don’ts of documentation, which can help guide proper documentation to reduce the potential for medical errors. Some of these include:

Patients and their families also play a large role in preventing medical errors. Emphasizing patient involvement in their care and safety is paramount. Interestingly, patients help detect medical errors and adverse events and, thus, should be encouraged to speak up about their care. Some studies have reported that patient satisfaction surveys have detected errors in the medical care they received that were otherwise not reported or discovered within the patient’s medical record. In many health facilities, patients and their family members are encouraged to alert rapid response teams if they are deteriorating or have a change in health status. In addition, healthcare team members should instill a trusting relationship with their patients and promote effective communication practices(Patient Safety Network, 2019).