At first glance administrative errors in healthcare might not seem to be the most exciting or engaging topic, however, as much as sometimes we would all like to ignore our own administrative burden, it remains at the heart of healthcare. 

At Medical Protection we aim to highlight areas of practice that can contribute to a complaint, claim or regulatory matter as we appreciate the stress this can cause our members. Often we focus on the clinical, technical and communication aspects of medicine, but increasingly we are noting that some of the cases arise from what can seem at first glance to be the most innocuous or simplest of administrative errors.

Unfortunately, these ‘simple’ errors can result in significant health consequences for the patient, distress for the doctor, financial and efficiency costs to the health provider due to increased hospital stay or increased staff workloads, large clinical negligence claim settlements and ultimately loss of patient trust in the healthcare professional and organisation. A 2024 WHO report¹ states that globally at least one in 20 patients experiences preventable medication related harm, with the cost of medication errors alone estimated at US$ 24 billion annually. So the issue is significant. 

In this article I aim to highlight some of the more common errors seen in our case files across all areas of healthcare, and provide some suggestions as to how they can be avoided. 

Medication 

A medication error is often described as ‘any preventable event that causes or leads to inappropriate medication use or patient harm while the medication is under the control of a health professional, patient or consumer’. The errors are common and often preventable and can be due to human factors such as fatigue, distractions and high workloads or from inadequate systems and processes. The commonest errors in the Medical Protection case files are from the following activities: 

• Medicine selection 

Although many clinicians now have the support of prescribing via electronic systems, errors still occur when clinicians override the alerts for allergies or potential reactions with other medications, often simply due to habitual clicking through of multiple alerts. In addition, selecting a similar sounding medication from a drop-down box, such as Xalatan rather than Xalacom eye drops, or Daktarin rather than Daktacort is easily done in haste.

• Writing prescriptions 
   

When transcribing medication it is easy to see how errors occur in prescribing the wrong medication, dose, rate or administration route or even writing the medication on the wrong patients record. For clinicians writing prescriptions by hand misinterpretation of illegible handwriting is not always picked up by the pharmacist or dispenser. Failure to adjust medications to patient specifics such as weight or renal function has also resulted in significant patient harm. For example, failing to recognise that the recorded weight for a paediatric patient was inconsistent with the child’s appearance, resulting in adequate antibiotics being given for suspected meningitis and a poor outcome for the patient.

Case Study

Dr X was a resident doctor working in the emergency department. Pt A, a 69-year-old female, presented with arm pain and rapid atrial fibrillation. Dr X consulted with the consultant cardiologist who advised a stat dose of digoxin and an amiodarone infusion. Dr X wrote up the prescription as advised but was distracted by an acutely unwell patient before he had chance to check the prescription chart. The nurse immediately set up the amiodarone as prescribed, however within a short time period the patient demonstrated respiratory distress and then collapsed. During the resuscitation it was discovered that the whole dose of amiodarone had been given within one hour, rather than as a slow infusion, as Dr X had omitted to add the infusion rate to the prescription. Sadly, Pt A died following the adverse event. 

• Repeat medications 

The prescription of repeat medications is commonplace and necessary to ensure efficiency for both patients and clinicians. Many cases arise from a failure to ensure regular medication reviews with the patient to check the medication is still required (particularly with opioids). The other common precipitant is a failure to monitor for the adverse effects of the medication, particularly for drugs that require regular blood test monitoring such as ACE-inhibitors, digoxin, lithium, methotrexate, etc. 

• Dispensing and administration 

Administration and dispensing errors often arise from incorrect route of administration, giving the medication to the wrong patient, or at the incorrect frequency or rate, and many times this can be due to not following established protocols already in place or due to human factors such as fatigue or stress.

Referrals, reports, and results 

Writing and receiving referrals, reports, and results is an unavoidable but crucial element of any medical practice, which requires significant time and attention. The advent of AI in healthcare brings with it the promise to ease that burden, however the responsibility for any errors is still likely to remain with the clinician for the foreseeable future² even when AI is used as an adjunct, so attention to detail remains critical. 

• Referrals 

Despite the clinicians’ best intentions delayed or missed referrals following an accurate patient assessment remain common in alleged delay in diagnosis claims, particularly in relation to cancer diagnoses. In addition, failing to advise or action the speed at which a patient should be seen (routine or urgent) has been deemed pertinent in many cases where the resulting delay has caused poorer outcomes or more significant treatment.

• Reports and results 

One of the most common causes of cases in this area is the failure to act on significant results, or letters from other clinicians. Routine tests, such as cervical smears, that throw up abnormal results, can easily be missed leading to the receiving clinician failing to arrange repeat tests or make appropriate referrals. Reports from radiology and pathology also feature highly in this context, where typographical errors, abbreviations or lack of clarity regarding next steps can lead to incorrect actions by the recipient. Perhaps AI could be a solution in screening results received? However, sometimes the normal results also need to be seen by a clinician as much as an abnormal result, take for example a patient with haematuria and a negative urine culture, which should prompt further investigation. Increasingly, we are also seeing misinterpretation of results given verbally in urgent situations and then failure to compare with the subsequent written report which may differ in detail.

Case study

Pt B was a 54-year-old man with persistent cough and back pain. Radiology revealed a lung mass, and the patient had a bronchoscopy and biopsy to determine the appropriate diagnosis and treatment, following which he had a review appointment with Dr X. Prior to the appointment Dr X rang the pathologist and was told that the likely diagnosis was adenocarcinoma, with a positive result for the EGFR mutation. Dr X explained the result to the patient and arranged for him to receive a targeted therapy drug suitable for the positive mutation. Six weeks later when Dr X was on leave, Dr Y saw Pt B and was surprised to note that he was receiving the targeted therapy when his pathology report stated the EGFR mutation was negative. Due to this error the patient had a reduced prognosis due to delay in receiving appropriate immunotherapy. On further analysis it appeared the error arose due to the pathologist providing the wrong patient’s results over the telephone, and the written report was not compared with the telephone result on receipt by Dr X.  

Patient identification 

The case study above involving Pt B is a clear example of the importance of correct patient identification. Despite the technological advances such as barcode scanning, and increased use of protocols these errors still occur, and the potential harms can range from minor to catastrophic. Some of the more serious consequences arise in the surgical arena, particularly in high volume specialties, where the wrong procedure is performed on a patient or the incorrect equipment or prosthesis used, for example, inserting the incorrect lens during a LASIK procedure due to confusion over which patient was next on the operating list.

Administrative staff 

In an article about administrative errors it would seem remiss to not mention the role of administrative staff. On the whole, support staff reduce our administrative burden, and often identify errors that assist both us and the patient. However, they can also play a role in communication, records and scheduling errors that shouldn’t be ignored. A claim in the UK³ demonstrated the impact of a receptionist providing well-meaning guidance about waiting times to a patient attending the emergency department with a head injury. Due to the misinformation the patient decided to return home where their condition suddenly deteriorated resulting in permanent brain damage. The Supreme Court judgment advised that the receptionist had a duty of care to provide accurate information and hence the hospital trust could be held liable for the subsequent injury to the patient.

However, it isn’t all bad news, as there are many ways which you can address these potential errors: 

Medication 

• Use the advantages of technology to assist you in prescribing and monitoring of medications, but don’t become desensitised to the alerts or prompts, and always ensure that you check the final outcome or prescription prior to pressing Enter. 

• When prescribing or reviewing medications ensure you have the right environment and time available, where possible, to ensure you can pay sufficient attention to the task at hand and avoid any interruptions or distractions. 

• When discussing repeat medications with patients engage them as an active participant in their care: ensure they understand the necessity and frequency of review, or requirement for blood tests as patients are an additional safety net if your administrative systems fail.

• If you are writing prescriptions by hand, avoid abbreviations but also ask your support staff how legible your writing is as their answer may surprise you. If the answer is negative consider what other options are available to you including increasing the size of your writing, using capitals or converting to electronic prescribing.

• Consider the HALT model (hungry, angry, lonely, tired): what can you do to address these factors as looking after yourself is key to preventing errors. 

Referrals, reports, and results 

• Ensure you have clear protocols in place regarding how test results and incoming patient correspondence should be addressed. Consider having a single return point for test results so you can ensure all tests requested have a matching result and to ensure consistency of action. Consider auditing your process at regular intervals to ensure it is still appropriate and accurate.

• When receiving results via any mode other that in writing repeat back the information to the provider to ensure accuracy, and always ensure that the final written result is checked alongside the verbal result. 

• When completing referrals or investigation requests ensure you have completed all areas of the request form, and make it clear where necessary when urgent attention is required. 

• When writing reports or documenting actions always re-read, particularly if using an AI scribe, to ensure the accuracy and clarity of your documentation. 

Patient identification 

• Use a minimum of two unique patient identifiers and have standard protocols for patient identification. 

• Consider using technology like barcode scanners or biometric systems as an adjunct for patient identification. 

• Always engage the patient (and family if necessary ) in the identification process.

Administrative staff 

• Provide regular training to support staff on how to address urgent presentations or at-risk groups of patients, including a clear escalation process.

• Review and re-circulate policies and guidance at regular intervals.

References 

1. Global burden of preventable medication-related harm in health care: a systematic review 

1. Avoiding the AI ‘off-switch’: Make AI work for clinicians, to unlock potential for patients 

1. Darnley v Croydon Health Services NHS Trust (2018)