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Section 6
Causes of Medical Errors

Question 6 | Test | Table of Contents

What is Root Cause Analysis?
Root cause analysis is a systematic investigation technique that looks beyond the affected individual and seeks to understand the underlying causes and environmental context in which an incident related to a medication error occurred. It is usually applied to serious adverse events or critical incidents, which are also known as, sentinel events.

What is a Sentinel Event?
A sentinel event is an unexpected occurrence that involves death or serious physical or psychological injury, or a risk thereof [9, 10]. The phrase ‘or a risk thereof’ includes any process variation a recurrence of which would carry a significant chance of a serious adverse outcome. Such events are called sentinel events because they signal the need for immediate investigation and response, as the term ‘signal’ implies in pharmacovigilance [11].

What the Mental Health Professional needs to Know about Prevention of Medical Errors
            Mental health professionals need to be aware of the adverse drug reactions and the importance of reporting possible medication errors. What procedures do you have in place in your inpatient of outpatient unit regarding:
1. Making therapist aware of the factors that cause medication errors,
2. Encouraging them to develop a safety culture that leads to enhanced awareness,
3. Stressing the need for commitment among mental healthcare professionals in becoming aware of medication errors client behavior which may indicate a medication error, and improving patient care.

Providing instruction to mental health professionals in your facility to be alerted regarding client behaviors which may be indicative of a medication error: can contribute to the detection and prevention of medication errors. Collaboration between therapists and prescribing doctors needs to be strengthened, in order to improve the quality of data collected, enhancing patient safety, and bridges need to be built linking policies dedicated to patient safety.

Medical Errors; Causes, Consequences, Emotional Response
and Resulting Behavioral Change

- Bari, A., Khan, R. A., & Rathore, A. W. (2016). Medical errors; causes, consequences, emotional response and resulting behavioral change. Pakistan journal of medical sciences, 32(3), 523–528. doi:10.12669/pjms.323.9701.

Reviewed 2023

Medication-related interventions to improve medication safety
and patient outcomes on transition from adult intensive care settings:
a systematic review and meta-analysis

Bourne, R. S., Jennings, J. K., Panagioti, M., Hodkinson, A., Sutton, A., & Ashcroft, D. M. (2022). Medication-related interventions to improve medication safety and patient outcomes on transition from adult intensive care settings: a systematic review and meta-analysis. BMJ quality & safety, 31(8), 609–622.

Peer-Reviewed Journal Article References:
Gillies, D., Chicop, D., & O'Halloran, P. (2015). Root cause analyses of suicides of mental health clients: Identifying systematic processes and service-level prevention strategies. Crisis: The Journal of Crisis Intervention and Suicide Prevention, 36(5), 316–324.

Katz-Navon, T., Naveh, E., & Stern, Z. (2009). Active learning: When is more better? The case of resident physicians’ medical errors. Journal of Applied Psychology, 94(5), 1200–1209.

Park, J., Goode, J., Tompkins, K. A., & Swift, J. K. (2016). Clinical errors that can occur in the treatment decision-making process in psychotherapy. Psychotherapy, 53(3), 257–261.

Reader, T. W., & Gillespie, A. (2021). Stakeholders in safety: Patient reports on unsafe clinical behaviors distinguish hospital mortality rates. Journal of Applied Psychology, 106(3), 439–451.

Robiner, W. N., Tompkins, T. L., & Hathaway, K. M. (2020). Prescriptive authority: Psychologists’ abridged training relative to other professions’ training. Clinical Psychology: Science and Practice, 27(1), Article e12309.

Zonana, J., Simberlund, J., & Christos, P. (2018). The impact of safety plans in an outpatient clinic. Crisis: The Journal of Crisis Intervention and Suicide Prevention, 39(4), 304–309.

Personal Reflection Exercise #6
The preceding section contained information about root cause and prevention.  Write one case study example regarding how you might use the content of this section in your practice.

What is a sentinel event? To select and enter your answer go to Test.

Section 7
Table of Contents

Excerpt from Bibliography

9 Haas D. Sentinel events. In memory of Ben – a case study. Jt Comm Perspect 1997; 17: 12–5.
10 Anonymous. Sentinel events: approaches to error reduction
and prevention. Jt Comm J Qual Improv 1998; 24: 175–86.
14 Benkirane RR, R-Abouqal R, Haimeur CC, El Kettani SEC,
Azzouzi AA, Alaoui AAM, Thimou AA, Nejmi MM, Maazouzi WW,Madani NN, Edwards IR, Soulaymani RR. Incidence of adverse drug events and medication errors in Intensive Care Units: a prospective multicenter study. J Patient Saf 2009; 5: 16–22