**5. Determinants of medical errors**

Literature also makes frequent reference to "adverse events," the severity, and criticality of which could have been significantly limited, provided that different actions had been fol-

In addition to the conceptual clarification of the term "adverse event," studies, such as the Harvard Medical Practice Study [20, 21] and the Utah and Colorado Medical Practice Study [22], introduced the term "negligent adverse event" for the first time as a subcategory of the "preventable adverse events," which, however, meet the legal criteria defining negligence.

Other than words such as "mistake," "error," and "adverse or undesirable event," literature regarding patient safety issues also makes frequent use of several relevant terms without any clear and distinct conceptual differentiation. According to Cook et al. [31], it is a fact that the

Another term similar to "adverse event" that ranks second in terms of incidence is the term "sentinel event." The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) (2003) defined it as an unexpected event that involves death, serious physical or psychological damage, or risk of those. Serious physical or psychological damage refers to the loss of a body part or a function, whereas the risk of such damages refers to any variation of the procedure, the revision of which would entail the risk of serious medical error occurrence or would pose a threat of an adverse event. The term "sentinel," is interpreted as a guard or a watchman and is used for events that require immediate investigation and handling [32].

**i.** any event that led to amputation of a human body part or loss of function, not related to

approach of patient safety issues is not the same among all healthcare professionals.

lowed (ameliorable adverse event) [30].

18 Vignettes in Patient Safety - Volume 3

**Figure 2.** Adverse events classification by Leape. Source: Leape [10].

**4. Other terms used in literature**

Such events are as follows:

the underlying disease; and

The first study regarding "errors" in the healthcare sector was conducted in 1960 at a New York City hospital and indicated that 60% of the "errors" are caused by healthcare professionals' negligence [39].

This study was followed by Vincent's research effort in 1989, which regarded the underlying causes of "errors" in the healthcare sector and classified them into the following categories [40]:

**Weaknesses of the system Clarification**

A set of interpersonal interactions and relationships is established between theoretical researchers, pharmaceutical industry, journalists, practicing medical professionals, and prospective patients such that researchers' involvement with the development of new drugs is inevitably a procedure in which a number of "goods" become fungible

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21

A considerable number of nursing tasks entail an extent of risk, and medication administration possibly carries the most extensive risk. Nursing stuff has followed, in the customary way, the five rights of medication administration (patient, drug, route,

Instructions of language usage in medical settings could be efficacious in classifying and giving attention to language barriers and would enhance knowledge of health

particular medication to be administered to an individual. The prescribing practitioner may also give a medication order orally to a licensed person such as a pharmacist or a

5–10% of adverse reactions to drugs are allergic. Allergy indicators are the outcome of a chain reaction that begins from the immune system. Your immune system controls

communication systems receive much less attention and the clinical adoption of even simpler services like voice mail or electronic mail is still not ordinary in a considerable

One more plan to decrease "medication error" is drug dosage standardization.

consequences for healthcare systems. Much attention has concentrated on the

carefulness of nursing acts and evaluations. Also, there may be skill-mix issues

The healthcare sector has an obligation to guarantee that their staff is skilled enough and confident in dealing with all particular kinds of feedback in a way that is

Standardization is a significant term in the healthcare industry. With hospital budgets getting tighter, standardization is perfect for operating under cost constraints. But the negativity connected with the term makes it not easy for providers and hospital

informational deficiency, role incompatibility, and environmental stress. There are five frequent responses used in dealing with conflict: forcing, accommodating, avoiding, compromising, and collaborating. Managers on healthcare sector should become

Standard doses minimize the interpatient variation of drug dosages

time, and dose) to help prevent errors

how your body protects itself

number of healthcare services

investigational medical device

management to encourage standardization to clinical end users Process standardization

individually centered

Copy of the instructions A medication order is written instructions provided by a prescribing practitioner for a

Allergic reactions As a whole, medications have the possibility to provoke side effects, but only about

Medication order tracking Hospital sector has long faced challenges connected with getting, written by hand, medication orders from the prescriber to the pharmacist

Patient transport process Patient transportation is a considerable action in healthcare with important resource

comfortable with using all of these approximations

Staffing and work allocation Allocation of nursing time to patients at an educated guess influences quality and

emergency transport of acute- and critical-care patients Conflict resolution There are four widespread sources for interpersonal conflict: personal differences,

Intra-hospital communication There is notable dialog of, and investment in, information technologies,

Use of devices Adverse Device Effect (ADE): adverse event connected with the use of an

inequalities

nurse

Dissemination of pharmaceutical knowledge

Control of medicine dosage and patient's identity authentication

Availability of information regarding the patient

Dosage standardization and administration frequency

Standardization of medical products distribution process within the department

Feedback following the emergence of unintended

events

Preparation of intravenous solutions by nurses

**Table 2.** The weaknesses of the system.


In his development of organizational accident causation model (Swiss cheese model applied to clinical events), Reason [6] suggests that a factor may cause more than one "error" and one "error" may be attributed to more than one factor. In the event, however, that no efforts are made in order to improve the overall factors causing the errors and address errors on an individual basis, no progress will be made and new errors will continue to arise. Reason grouped the factors that influence clinical practice negatively into five levels [6, 40].

In 1995, Leape et al. published one of the largest studies regarding "errors," which constituted a key presumption for the need to study organizational factors that contribute to the occurrence of "errors" [9]. The study examined the weaknesses of the system that led to the emergence of 334 errors. The authors attempted to answer three major questions: (1) why did the error occur, (2) which was the basic cause of the error, and (3) what were the system's weaknesses. According to the findings of the study, the weaknesses of the system may be categorized as listed in **Table 2**.

A similar classification of "error determinants" was also attempted by Helmreich in the "The university of Texas Threat and error management model" in 2000. Helmreich distinguished between the organizational factors, the individual factors, and factors regarding teamwork and the patient [41].

Carver and Hipskind [43] confirm that a medical error is an "avoidable adverse effect" of medical care, whether or not it is substance to the patient. Among the difficulties that usually happen throughout providing healthcare are adverse drug events and irregular transfusions, incorrect identification of an illness, under- and overtreatment, surgical injuries and wrong-site surgery, suicides, restraint-related injuries or death, falls, burns, pressure ulcers, and incorrect patient identities. High error rates with important effects are most probable to happen in intensive care units (ICUs) [42], operating room (OR), and emergency departments (EDs). Furthermore, "medical errors" are connected with unused procedures, immediate necessity, and the seriousness of the medical condition being treated [43].

The responsibility for the emergence of errors is apportioned among the nature of the healthcare system that is characterized by organizational and functional complexity, the multifaceted and uncertain nature of medical science, and the imperfections of human nature [44, 45].

#### **5.1. Factors related to the nature of the healthcare system**

According to the theory of physical accidents, which was formulated for the first time in 1984 by the sociologist Charles Perrow, accidents are inevitable; therefore, they occur naturally,


**Table 2.** The weaknesses of the system.

This study was followed by Vincent's research effort in 1989, which regarded the underlying causes of "errors" in the healthcare sector and classified them into the following categories [40]:

**ii.** temporary situations such as the consumption of pharmaceutical preparations and alco-

In his development of organizational accident causation model (Swiss cheese model applied to clinical events), Reason [6] suggests that a factor may cause more than one "error" and one "error" may be attributed to more than one factor. In the event, however, that no efforts are made in order to improve the overall factors causing the errors and address errors on an individual basis, no progress will be made and new errors will continue to arise. Reason grouped

In 1995, Leape et al. published one of the largest studies regarding "errors," which constituted a key presumption for the need to study organizational factors that contribute to the occurrence of "errors" [9]. The study examined the weaknesses of the system that led to the emergence of 334 errors. The authors attempted to answer three major questions: (1) why did the error occur, (2) which was the basic cause of the error, and (3) what were the system's weaknesses. According to the findings of the study, the weaknesses of the system may be

A similar classification of "error determinants" was also attempted by Helmreich in the "The university of Texas Threat and error management model" in 2000. Helmreich distinguished between the organizational factors, the individual factors, and factors regarding teamwork

Carver and Hipskind [43] confirm that a medical error is an "avoidable adverse effect" of medical care, whether or not it is substance to the patient. Among the difficulties that usually happen throughout providing healthcare are adverse drug events and irregular transfusions, incorrect identification of an illness, under- and overtreatment, surgical injuries and wrong-site surgery, suicides, restraint-related injuries or death, falls, burns, pressure ulcers, and incorrect patient identities. High error rates with important effects are most probable to happen in intensive care units (ICUs) [42], operating room (OR), and emergency departments (EDs). Furthermore, "medical errors" are connected with unused procedures, immediate

The responsibility for the emergence of errors is apportioned among the nature of the healthcare system that is characterized by organizational and functional complexity, the multifaceted and uncertain nature of medical science, and the imperfections of human nature [44, 45].

According to the theory of physical accidents, which was formulated for the first time in 1984 by the sociologist Charles Perrow, accidents are inevitable; therefore, they occur naturally,

**i.** individual characteristics of health professionals that commit the errors,

the factors that influence clinical practice negatively into five levels [6, 40].

necessity, and the seriousness of the medical condition being treated [43].

**5.1. Factors related to the nature of the healthcare system**

hol by health professionals,

**iii.** organizational factors, and

categorized as listed in **Table 2**.

and the patient [41].

**iv.** patients' characteristics.

20 Vignettes in Patient Safety - Volume 3

since they constitute inherent features of complex systems. The more complex a system is and the stronger the bonds between the individual elements of the system are, the more complicated and unpredictable are the consequences from a possible error. Perrow uses the term "accident" in order to describe a fact that entails damage to a given system that disorganizes the consecutive or future outcome of the system [46]. Perrow's theory is also supported by Reason in 1990, who argues that complex systems entail unfavorable developments. This is the reason why complex systems provide multiple methods for error detection and recording [6].

With regard to individual factors, demographic parameters reveal that age appears to be systematically associated with "professional burnout," with the younger employees exhibiting it to a larger degree [52–54, 58]. In relation to gender, the findings are contradictory [54, 66–69] although studies reveal that higher levels of professional stress for women are systematically encountered [66, 67]. Marriage appears to have a protective effect on the occurrence of "professional burnout" in women. Support provided by husbands or wives as well as work life balance are also among the factors that systematically demonstrate negative correlation with

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23

Among the personality traits systematically associated with "professional burnout" are empowerment [70], empathy [70], tolerance to stress [71, 72], sense of effectiveness [54], and

The effects of "professional burnout" on physicians and nurses are manifested not only on the individual level but also on the organizational, thus affecting the quality of the healthcare provision at the organization in which they are occupied. "Professional burnout" may also cause physiological symptoms to employees either in the form of plain discomfort or more serious health problems, emotional problems such as the feeling of discouragement, low self-esteem and self-confidence, behavioral symptoms such as coldness, indifference, lack of care interest and respect for the patients, and psychiatric disorders such as stress and depression. There is also evidence that "professional burnout" may influence individuals' satisfaction regarding life in general, their social and personal life and may also be contagious to other health profes-

The effects of professional burnout expand, as previously mentioned, to the healthcare provision organization, increasingly slowing the implementation of the employees' project, leading to absences and reduced performance. It has also been associated with an increased intention of the personnel to leave employment/retire [53, 64, 75]. "Early" retirement of physicians and nurses intensifies the already existing problem of staff shortage contributing to the lower quality of offered services, since insufficient staffing is associated with patient mortality, adverse events, and the quality of services provided, as substantiated by the existent literature [64]. The retirement of the aforementioned health professionals also has a financial impact to

Shanafelt et al. [62] examined the relationship between burnout in medical residents and their opinion regarding their practices regarding healthcare provision to patients. On the one hand, according to the findings, 76% of the physicians who participated in the study suffered from professional burnout. On the other hand, "burnout physicians" were more likely to report "inappropriate patient healthcare practices," such as inappropriate behavior toward patients, omissions in diagnostic treatment, and medication errors at least on a weekly or a monthly

Workload has been directly associated with the emergence of errors during clinical practice and is mainly attributed to the lack of personnel [47, 64, 76, 77]. Understaffed healthcare units

the organization, as the latter bears a large cost for their replacement [11].

basis, in comparison to those that did not suffer from a professional burnout [62].

"professional burnout" [54].

sionals (colleagues or trainees) [74].

*5.2.2. Workload*

mental well-being [73].

Another key factor that determines errors in the healthcare sector is technology. Problems often arise from human interaction with technology, or insufficiency, or poor maintenance of the technological equipment. This fact is proven in a study by Taxis and Barber [47], in relation to intravenous (IV) medication errors, where 79% of errors are associated with the lack of knowledge regarding the drug preparation and administration and machinery operation (e.g., pumps). According to the results of a current study, the unforeseen potentially fatal events within 24 h of admission from the ED could be a helpful trigger tool to recognize "preventable adverse events" with grave harms to body in ED [48].

#### **5.2. Factors associated with the healthcare professionals' human nature**

"Medical and nursing errors" are human errors committed by persons acting in a certain capacity (physicians, nurses), in a certain environment, and under special conditions. Human intelligence is not infallible; therefore, the resulting action cannot be infallible. Causes associated with the human factor contributing to the emergence of errors in the healthcare sector are the following.

#### *5.2.1. Professional burnout*

The term "professional burnout" was used in literature for the first time in 1974 by Freundenburger. In one of his articles, he described the psychosomatic symptoms that appeared in healthcare professionals occupied with mental illnesses [49]. In 1982, Christina Maslach described this phenomenon as "a syndrome of mental and physical exhaustion, where an employee loses interest for the patients, ceases to be satisfied from his/her work and performance, and forms a negative opinion about his/her self" [50]. According to Maslach and Jackson [51], the three most important components of burnout are the emotional burnout, depersonalization or cynicism, and the sense of ineffectiveness (lack of personal achievements).

According to international studies, the factors relating to "professional burnout" are categorized into factors relevant to the working environment, individual factors, and personality factors. Workload [52–55], high stress levels [56–59], conflicts with colleagues superiors or relatives [59, 60], social support from colleagues and superiors [52, 55], job satisfaction [59, 61, 62], balance among work family and personal development [53, 55], sense of control [53], organizational support [55, 63], autonomy [52, 53], inadequate time to study [52, 62], sufficient staffing [63–65], training in communicational skills [58], and salaries [52, 53] are among the factors relating to the working environment, which are systematically highlighted as closely linked to a professional burnout caused at physicians and nurses.

With regard to individual factors, demographic parameters reveal that age appears to be systematically associated with "professional burnout," with the younger employees exhibiting it to a larger degree [52–54, 58]. In relation to gender, the findings are contradictory [54, 66–69] although studies reveal that higher levels of professional stress for women are systematically encountered [66, 67]. Marriage appears to have a protective effect on the occurrence of "professional burnout" in women. Support provided by husbands or wives as well as work life balance are also among the factors that systematically demonstrate negative correlation with "professional burnout" [54].

Among the personality traits systematically associated with "professional burnout" are empowerment [70], empathy [70], tolerance to stress [71, 72], sense of effectiveness [54], and mental well-being [73].

The effects of "professional burnout" on physicians and nurses are manifested not only on the individual level but also on the organizational, thus affecting the quality of the healthcare provision at the organization in which they are occupied. "Professional burnout" may also cause physiological symptoms to employees either in the form of plain discomfort or more serious health problems, emotional problems such as the feeling of discouragement, low self-esteem and self-confidence, behavioral symptoms such as coldness, indifference, lack of care interest and respect for the patients, and psychiatric disorders such as stress and depression. There is also evidence that "professional burnout" may influence individuals' satisfaction regarding life in general, their social and personal life and may also be contagious to other health professionals (colleagues or trainees) [74].

The effects of professional burnout expand, as previously mentioned, to the healthcare provision organization, increasingly slowing the implementation of the employees' project, leading to absences and reduced performance. It has also been associated with an increased intention of the personnel to leave employment/retire [53, 64, 75]. "Early" retirement of physicians and nurses intensifies the already existing problem of staff shortage contributing to the lower quality of offered services, since insufficient staffing is associated with patient mortality, adverse events, and the quality of services provided, as substantiated by the existent literature [64]. The retirement of the aforementioned health professionals also has a financial impact to the organization, as the latter bears a large cost for their replacement [11].

Shanafelt et al. [62] examined the relationship between burnout in medical residents and their opinion regarding their practices regarding healthcare provision to patients. On the one hand, according to the findings, 76% of the physicians who participated in the study suffered from professional burnout. On the other hand, "burnout physicians" were more likely to report "inappropriate patient healthcare practices," such as inappropriate behavior toward patients, omissions in diagnostic treatment, and medication errors at least on a weekly or a monthly basis, in comparison to those that did not suffer from a professional burnout [62].

#### *5.2.2. Workload*

since they constitute inherent features of complex systems. The more complex a system is and the stronger the bonds between the individual elements of the system are, the more complicated and unpredictable are the consequences from a possible error. Perrow uses the term "accident" in order to describe a fact that entails damage to a given system that disorganizes the consecutive or future outcome of the system [46]. Perrow's theory is also supported by Reason in 1990, who argues that complex systems entail unfavorable developments. This is the reason why complex systems provide multiple methods for error detection and recording [6].

Another key factor that determines errors in the healthcare sector is technology. Problems often arise from human interaction with technology, or insufficiency, or poor maintenance of the technological equipment. This fact is proven in a study by Taxis and Barber [47], in relation to intravenous (IV) medication errors, where 79% of errors are associated with the lack of knowledge regarding the drug preparation and administration and machinery operation (e.g., pumps). According to the results of a current study, the unforeseen potentially fatal events within 24 h of admission from the ED could be a helpful trigger tool to recognize "pre-

"Medical and nursing errors" are human errors committed by persons acting in a certain capacity (physicians, nurses), in a certain environment, and under special conditions. Human intelligence is not infallible; therefore, the resulting action cannot be infallible. Causes associated with the human factor contributing to the emergence of errors in the healthcare sector

The term "professional burnout" was used in literature for the first time in 1974 by Freundenburger. In one of his articles, he described the psychosomatic symptoms that appeared in healthcare professionals occupied with mental illnesses [49]. In 1982, Christina Maslach described this phenomenon as "a syndrome of mental and physical exhaustion, where an employee loses interest for the patients, ceases to be satisfied from his/her work and performance, and forms a negative opinion about his/her self" [50]. According to Maslach and Jackson [51], the three most important components of burnout are the emotional burnout, depersonali-

According to international studies, the factors relating to "professional burnout" are categorized into factors relevant to the working environment, individual factors, and personality factors. Workload [52–55], high stress levels [56–59], conflicts with colleagues superiors or relatives [59, 60], social support from colleagues and superiors [52, 55], job satisfaction [59, 61, 62], balance among work family and personal development [53, 55], sense of control [53], organizational support [55, 63], autonomy [52, 53], inadequate time to study [52, 62], sufficient staffing [63–65], training in communicational skills [58], and salaries [52, 53] are among the factors relating to the working environment, which are systematically highlighted as closely

zation or cynicism, and the sense of ineffectiveness (lack of personal achievements).

linked to a professional burnout caused at physicians and nurses.

ventable adverse events" with grave harms to body in ED [48].

are the following.

*5.2.1. Professional burnout*

22 Vignettes in Patient Safety - Volume 3

**5.2. Factors associated with the healthcare professionals' human nature**

Workload has been directly associated with the emergence of errors during clinical practice and is mainly attributed to the lack of personnel [47, 64, 76, 77]. Understaffed healthcare units in combination with workload are likely to endanger patient's safety [76]. A study conducted in 1998 in Australia by Beckmann et al. has shown that lack of personnel is associated with increased medication errors, inadequate patient supervision, equipment preparation, and omissions in documentation of medical and nursing care [78]. Similar were the findings of a study by Giraud et al., in 1993, which identified heavy workload as the main cause for an increasing rate of errors [79]. In a study realized by Blendon et al. [80], the physicians participating in the research argued that the main cause of errors in clinical practice is the lack of nursing personnel.

IV medication errors, 16% of the errors are associated with poor communication among healthcare professionals, whereas in a study by Blendon et al. [80], physicians argue that poor communication among professionals causes errors at a level of 39%. In the same study, the citizens, who were also included in the study responded that poor communication among healthcare professionals promotes errors at a level of 67%. Mayo and Duncan [82] also believe that conversations between nurses and supervisors regarding errors that are considered a "taboo" are necessary. Interprofessional cooperation between physicians and nurses is also of significant importance. The fact that is of particular importance in Arndt's [84] study is that some physicians had a good communication and cooperation with the nurses, and often after evaluating the error and provided no serious damage was caused to the patient, they covered up for the errors realized by the nurses. According to Helmreich [41], the risk of errors in surgeries increases when there are problems in communication, information transmission, leadership, interpersonal relationships, and conflicts. Van Cott [88] generally indicates that a high rate of errors results from communication problems, oral or written, which can be prevented provided appropriate training is present. Cooke and Salas [89] highlighted that in a stressful environment, people tend to fail to express orally what they mean. Even if they do manage to express it orally, it is not certain that the intended recipients will hear it. Even if they hear it, it is not certain that they will understand it. Finally, even if they do understand it, it is not certain that they will act accordingly. It is for this reason that confirmation should be required,

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25

Roseman and Booker [81] examined the association between "medication errors" and daytime, the latter being an environmental specificity regarding a particular geographical area. The study was conducted in Anchorage in Alaska, where daytime is gradually changing from 5.5 h in December to 19.5 h in June. This change in daytime throughout the year leads to mood disorders called "Seasonal Affective Disorder (SAD)," which is characterized by a recurring depression in the fall or in the winter that normally resolves in the spring. More than half of the errors occurred in the first quarter of the year, and, more specifically, 22% of the errors occurred in February and 29% in March. This finding is considered significant; however, fur-

Other than the error factors that are associated with the healthcare system per se and the factors related to the human nature, there are also factors related with the uncertain and multifaceted nature of medical science. Every medical action initially affects the bodily integrity and secondarily the patient's personality and privacy. Every medical and nursing intervention poses threats, which according to the law of probability will eventually be realized. Medicine and Nursing are empirical sciences, and the uncertainty factor lurks in every stage of healthcare provision (prevention, diagnosis, treatment, research). Patients and their relatives are not trained to identify the finite limits of the medical science in the case of aggressive

in order to prevent a gap between the abovementioned steps [89].

**5.3. Factors associated with the nature of medical science**

*5.2.5. Environmental conditions*

ther research is required [81].

diseases and death [90, 91].

In their research published in 1995, Roseman and Booker demonstrated the correlation between workload and the errors in healthcare, quantifying workload with the use of nine indexes. It was found that three out of nine workload indexes that were examined (number of patient days per month, number of emergency shift staff, and overtime of permanent nursing staff) could significantly predict the risk of medication error. More specifically, the number of errors increased as the number of patient days and the number of emergency staff's shifts increased, whereas it decreased as the number of overtime of the permanent nursing staff increased. The latter is reasonable, since permanent nursing staff is better trained and oriented in a specific department compared to emergency staff [81]. According to the findings of Mayo and Duncan's study [82], the interruption of nurses by a relative or another healthcare professional during the preparation of medication is ranked second among the factors that cause the emergence of errors. However, a study by Osborne et al. [83] ranks the same factor as fourth.

#### *5.2.3. Lack of knowledge and experience*

According to a study realized by Arndt [84], regarding the effects of errors on nurses' psychology, the respondents reported that errors were caused by lack of knowledge regarding medicine administration. In a study by Taxis and Barber [47], regarding intravenous medication errors, 79% of errors were related to lack of knowledge regarding medicine preparation, administration, and machine operation (pumps), and 15% were related to heavy workload and often interruptions. Blais and Bath [85] identified three categories of errors relevant to the calculation of drug dosage: mathematical, conceptual, and measurement errors. In Osborne's study [83], 5.3% of errors are caused by wrong calculations. The experience of healthcare professionals constitutes another factor regarding errors. In his study, Walters [86] mentions that there is a statistically important relation between the number of errors made by nurses with a greater working experience (less errors) and the errors made by professionals with less working experience (more errors). Due to the lack of experience, newly recruited healthcare professionals are the first to blame when an error occurs. In several occasions, however, newly recruited in the unit are hesitant and lack initiatives out of fear of making an error that may have adverse effects on patients' health status. On the other hand and according to the study, the most experienced professionals are those that indeed make fewer errors compared to beginners [87]; however, they may commit errors with very serious consequences for patients' health status [7].

#### *5.2.4. Communication difficulties among healthcare professionals*

Communication among healthcare professionals constitutes an important factor not only for preventing but also for making errors [76]. In a study by Taxis and Barber [47], regarding IV medication errors, 16% of the errors are associated with poor communication among healthcare professionals, whereas in a study by Blendon et al. [80], physicians argue that poor communication among professionals causes errors at a level of 39%. In the same study, the citizens, who were also included in the study responded that poor communication among healthcare professionals promotes errors at a level of 67%. Mayo and Duncan [82] also believe that conversations between nurses and supervisors regarding errors that are considered a "taboo" are necessary. Interprofessional cooperation between physicians and nurses is also of significant importance. The fact that is of particular importance in Arndt's [84] study is that some physicians had a good communication and cooperation with the nurses, and often after evaluating the error and provided no serious damage was caused to the patient, they covered up for the errors realized by the nurses. According to Helmreich [41], the risk of errors in surgeries increases when there are problems in communication, information transmission, leadership, interpersonal relationships, and conflicts. Van Cott [88] generally indicates that a high rate of errors results from communication problems, oral or written, which can be prevented provided appropriate training is present. Cooke and Salas [89] highlighted that in a stressful environment, people tend to fail to express orally what they mean. Even if they do manage to express it orally, it is not certain that the intended recipients will hear it. Even if they hear it, it is not certain that they will understand it. Finally, even if they do understand it, it is not certain that they will act accordingly. It is for this reason that confirmation should be required, in order to prevent a gap between the abovementioned steps [89].

#### *5.2.5. Environmental conditions*

in combination with workload are likely to endanger patient's safety [76]. A study conducted in 1998 in Australia by Beckmann et al. has shown that lack of personnel is associated with increased medication errors, inadequate patient supervision, equipment preparation, and omissions in documentation of medical and nursing care [78]. Similar were the findings of a study by Giraud et al., in 1993, which identified heavy workload as the main cause for an increasing rate of errors [79]. In a study realized by Blendon et al. [80], the physicians participating in the research argued that the main cause of errors in clinical practice is the lack of nursing personnel. In their research published in 1995, Roseman and Booker demonstrated the correlation between workload and the errors in healthcare, quantifying workload with the use of nine indexes. It was found that three out of nine workload indexes that were examined (number of patient days per month, number of emergency shift staff, and overtime of permanent nursing staff) could significantly predict the risk of medication error. More specifically, the number of errors increased as the number of patient days and the number of emergency staff's shifts increased, whereas it decreased as the number of overtime of the permanent nursing staff increased. The latter is reasonable, since permanent nursing staff is better trained and oriented in a specific department compared to emergency staff [81]. According to the findings of Mayo and Duncan's study [82], the interruption of nurses by a relative or another healthcare professional during the preparation of medication is ranked second among the factors that cause the emergence of errors. However, a study by Osborne et al. [83] ranks the same factor as fourth.

According to a study realized by Arndt [84], regarding the effects of errors on nurses' psychology, the respondents reported that errors were caused by lack of knowledge regarding medicine administration. In a study by Taxis and Barber [47], regarding intravenous medication errors, 79% of errors were related to lack of knowledge regarding medicine preparation, administration, and machine operation (pumps), and 15% were related to heavy workload and often interruptions. Blais and Bath [85] identified three categories of errors relevant to the calculation of drug dosage: mathematical, conceptual, and measurement errors. In Osborne's study [83], 5.3% of errors are caused by wrong calculations. The experience of healthcare professionals constitutes another factor regarding errors. In his study, Walters [86] mentions that there is a statistically important relation between the number of errors made by nurses with a greater working experience (less errors) and the errors made by professionals with less working experience (more errors). Due to the lack of experience, newly recruited healthcare professionals are the first to blame when an error occurs. In several occasions, however, newly recruited in the unit are hesitant and lack initiatives out of fear of making an error that may have adverse effects on patients' health status. On the other hand and according to the study, the most experienced professionals are those that indeed make fewer errors compared to beginners [87]; however,

they may commit errors with very serious consequences for patients' health status [7].

Communication among healthcare professionals constitutes an important factor not only for preventing but also for making errors [76]. In a study by Taxis and Barber [47], regarding

*5.2.4. Communication difficulties among healthcare professionals*

*5.2.3. Lack of knowledge and experience*

24 Vignettes in Patient Safety - Volume 3

Roseman and Booker [81] examined the association between "medication errors" and daytime, the latter being an environmental specificity regarding a particular geographical area. The study was conducted in Anchorage in Alaska, where daytime is gradually changing from 5.5 h in December to 19.5 h in June. This change in daytime throughout the year leads to mood disorders called "Seasonal Affective Disorder (SAD)," which is characterized by a recurring depression in the fall or in the winter that normally resolves in the spring. More than half of the errors occurred in the first quarter of the year, and, more specifically, 22% of the errors occurred in February and 29% in March. This finding is considered significant; however, further research is required [81].

#### **5.3. Factors associated with the nature of medical science**

Other than the error factors that are associated with the healthcare system per se and the factors related to the human nature, there are also factors related with the uncertain and multifaceted nature of medical science. Every medical action initially affects the bodily integrity and secondarily the patient's personality and privacy. Every medical and nursing intervention poses threats, which according to the law of probability will eventually be realized. Medicine and Nursing are empirical sciences, and the uncertainty factor lurks in every stage of healthcare provision (prevention, diagnosis, treatment, research). Patients and their relatives are not trained to identify the finite limits of the medical science in the case of aggressive diseases and death [90, 91].
