The quiet machinery that helps to keep patients safe

Dr Sarah Townley explains that while ‘admin’ may not be the most exciting part of medicine, it sits at the heart of safe healthcare

At Medical Protection, our ethos remains to help members avoid problems occurring in the first place, and we regularly highlight areas of practice that can contribute to complaints, claims or regulatory matters. Often our focus is on the clinical, technical, and communication aspects of medicine. But increasingly we are noting cases arising from what appear at first glance to be the most innocuous or simplest of administrative errors.

These ‘simple’ errors can result in significant health consequences for patients, distress for doctors, and financial and efficiency costs to the health provider. This may be due to increased hospital stays, increased staff workloads, large clinical negligence claim settlements, and ultimately loss of patient trust in the healthcare professional and organisation.

In this article I will highlight some of the common administration-related errors seen in Medical Protection’s case files and provide suggestions to help avoid them.

Medication

Medication errors are common, often preventable, and can be due to human factors, such as fatigue, distractions, and high workload, or from inadequate systems and processes. A 2024 World Health Organisation report states that globally at least one in 20 patients experience preventable medication-related harm, with the cost of medication errors alone estimated at US$24 billion annually, so the issue is not insignificant. The most common errors from our case files arise from the following:

Medication errors are common, often preventable, and can be due to human factors, such as fatigue, distractions, and high workload, or from inadequate systems and processes

Medicine selection

Although many clinicians now have the support of prescribing via electronic systems, errors still occur when clinicians override alerts for allergies or potential reactions with other medications. 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 patient’s record. For clinicians who write prescriptions by hand, illegible handwriting may be misinterpreted, and is not always identified by the pharmacist or dispenser. Failure to adjust medications to patient-specific factors, such as weight or renal function, has also led to significant patient harm. For example, failure to recognise that the recorded weight for a paediatric patient was inconsistent with the child’s appearance resulted in inadequate antibiotics being administered for suspected meningitis and a poor outcome for the patient.

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 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. Many times this can be due to not following established protocols already in place or human factors such as fatigue or stress. 

Referrals, reports, and results

Writing and receiving referrals, reports and results requires significant time and attention. The advent of artificial intelligence (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 future 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. AI could be a solution in screening results received; however, sometimes normal results 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.

Patient identification

Despite technological advances, such as barcode scanning and increased use of protocols, patient identification errors still occur. 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 colleagues

In an article about administrative errors, it would seem remiss not to mention the role of administrative colleagues. On the whole, these colleagues reduce our administrative burden and often identify errors that assist both the clinician and the patient. However, they can play a role in communication, record-keeping, and scheduling errors. For instance, a claim 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 incorrect information provided, the patient made the decision to return home where their condition suddenly deteriorated resulting in permanent brain damage. The court judgment advised that the receptionist had a duty of care to provide accurate information and hence the hospital could be held liable for the subsequent injury to the patient.

While errors do happen, it is important to consider any steps which may reduce the risk of occurrence. For example:

Medication

▶ Leverage technology to assist you in prescribing and monitoring medication, but do not become desensitised to 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 are in the right environment and have time available, where possible, to pay sufficient attention to the task at hand without 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 the requirement for blood tests. Patients can be an additional safety net if your administrative systems fail.

▶ If you are writing prescriptions by hand, avoid abbreviations and consider asking your support colleagues how legible your writing is. If required, explore options including increasing the size of your writing, using capitals or converting to electronic prescribing.

▶ Consider the HALT model (hungry, angry, lonely, tired). Looking after yourself is key to preventing errors.

Referrals, reports, and results

▶ Create clear protocols for handling test results and incoming patient correspondence.

▶ Consider having a single return point for test results so you can ensure all tests requested have a matching result. Consider auditing your process regularly to ensure it is still appropriate and accurate.

▶ When receiving results via any mode other than in writing, repeat back the information to the provider to ensure accuracy, and always check the final written result alongside the verbal result.

▶ Complete all sections of referral forms or investigation requests and make it clear 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.

Patient identification

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

▶ Consider barcode scanners or biometric systems as an adjunct for patient identification.

▶ Always engage patients (and family if necessary) in the identification process.

Administrative colleagues

▶ Provide regular training for support colleagues on how to address urgent presentations or at-risk patients, including a clear escalation process.

▶ Regularly review and re-circulate policies.

References available on request