medical error

A medical error occurs when a health-care provider chooses an inappropriate method of care or improperly executes an appropriate method of care. Medical errors are often described as human errors in healthcare.{{cite journal | author = Zhang, J., Patel, V.L., & Johnson, T.R | year = 2008 | title = Medical error: Is the solution medical or cognitive?| journal = Journal of the American Medical Informatics Association | volume = 6 | issue = Supp1 | pages = 75–77 | doi = 10.1197/jamia.M1232| pmid = 12386188 | pmc = 419424 }}

There are many types of medical error, from minor to major,{{cite journal |last1=Hofer |first1=TP |last2=Kerr |first2=EA |last3=Hayward |first3=RA |title=What is an error? |journal=Effective Clinical Practice |year=2000 |volume=3 |issue=6 |pages=261–9 |pmid=11151522 |url=http://www.acponline.org/journals/ecp/novdec00/hofer.htm |access-date=June 11, 2007 |archive-url=https://web.archive.org/web/20070928004341/http://www.acponline.org/journals/ecp/novdec00/hofer.htm |archive-date=September 28, 2007 |url-status=dead }} and causality understanding and assessing if the likelihood that the specific event or factor was responsible for the negative outcome, is often poorly determined.{{cite journal |doi=10.1001/jama.286.4.415 |title=Estimating Hospital Deaths Due to Medical Errors: Preventability Is in the Eye of the Reviewer |last1=Hayward |first1=Rodney A. |last2=Hofer |first2=Timothy P. |date=July 25, 2001 |journal=JAMA |volume=286 |issue=4 |pages=415–20 |pmid=11466119}}{{Citation |last=Singh |first=Gunjan |title=Root Cause Analysis and Medical Error Prevention |date=2025 |work=StatPearls |url=https://www.ncbi.nlm.nih.gov/books/NBK570638/ |access-date=2025-04-15 |place=Treasure Island (FL) |publisher=StatPearls Publishing |pmid=34033400 |last2=Patel |first2=Raj H. |last3=Vaqar |first3=Sarosh |last4=Boster |first4=Joshua}}

There are many taxonomies for classifying medical errors.{{cite journal |last1=Kopec |first1=D. |last2=Tamang |first2=S. |last3=Levy |first3=K. |last4=Eckhardt |first4=R. |last5=Shagas |first5=G. |title=The state of the art in the reduction of medical errors |journal=Studies in Health Technology and Informatics |year=2006 |volume=121 |pages=126–37 |pmid=17095810}}

Defining diagnostic error is important for measuring its frequency, identifying its causes, and implementing strategies to reduce harm and these steps that are essential for improving patient safety.{{Cite book |url=https://nap.nationalacademies.org/catalog/21794/improving-diagnosis-in-health-care |title=Improving Diagnosis in Health Care |date=2015-12-29 |publisher=National Academies Press |others=Committee on Diagnostic Error in Health Care, Board on Health Care Services, Institute of Medicine, The National Academies of Sciences, Engineering, and Medicine |isbn=978-0-309-37769-0 |editor-last=Balogh |editor-first=Erin P. |location=Washington, D.C. |editor-last2=Miller |editor-first2=Bryan T. |editor-last3=Ball |editor-first3=John R.}} The complexity of diagnosis as both a process and an outcome has led to multiple, overlapping definitions and there is no single definition of diagnostic error. One challenge is reflected in part the dual nature of the word diagnosis, which is both a noun (the name of the assigned disease; diagnosis is a label) and a verb (the act of arriving at a diagnosis; diagnosis is a process).{{Citation needed|date=April 2025}} At the present time, there are at least 4 definitions of diagnostic error in active use:

Diagnostic error has been defined as a diagnosis that is wrong, egregiously delayed, or missed altogether.{{cite journal | last1=Graber | first1=Mark L. | last2=Franklin | first2=Nancy | last3=Gordon | first3=Ruthanna | title=Diagnostic error in internal medicine | journal=Archives of Internal Medicine | volume=165 | issue=13 | date=2005-07-11 | issn=0003-9926 | pmid=16009864 | doi=10.1001/archinte.165.13.1493 | pages=1493–1499}} This is a "label" definition, and can only be applied in retrospect, using some gold standard (for example, autopsy findings or a definitive laboratory test) to confirm the correct diagnosis. Many diagnostic errors fit several of these criteria; the categories overlap.

Diagnostic error has also be defined using process-related definitions: Schiff et al. defined diagnostic error as any breakdown in the diagnostic process, including both errors of omission and errors of commission.{{cite journal | last1=Schiff | first1=Gordon D. | last2=Hasan | first2=Omar | last3=Kim | first3=Seijeoung | last4=Abrams | first4=Richard | last5=Cosby | first5=Karen | last6=Lambert | first6=Bruce L. | last7=Elstein | first7=Arthur S. | last8=Hasler | first8=Scott | last9=Kabongo | first9=Martin L. | last10=Krosnjar | first10=Nela | last11=Odwazny | first11=Richard | last12=Wisniewski | first12=Mary F. | last13=McNutt | first13=Robert A. | title=Diagnostic error in medicine: analysis of 583 physician-reported errors | journal=Archives of Internal Medicine | volume=169 | issue=20 | date=2009-11-09 | issn=1538-3679 | pmid=19901140 | doi=10.1001/archinternmed.2009.333 | pages=1881–1887}} Similarly, Singh et al. defined diagnostic error as a "missed opportunity" in the diagnostic process, based on retrospective review.{{cite journal | last=Singh | first=Hardeep | title=Editorial: Helping health care organizations to define diagnostic errors as missed opportunities in diagnosis | journal=Joint Commission Journal on Quality and Patient Safety | volume=40 | issue=3 |year=2014 | issn=1553-7250 | pmid=24730204 | doi=10.1016/s1553-7250(14)40012-6 | pages=99–101}}

In its landmark report, Improving Diagnosis in Health Care, The National Academy of Medicine proposed a new, hybrid definition that includes both label- and process-related aspects: "A diagnostic error is failure to establish an accurate and timely explanation of the patient's health problem(s) or to communicate that explanation to the patient."{{cite book | title=Improving Diagnosis in Health Care | publisher=National Academies Press | publication-place=Washington, D.C. | date=2015-12-29 | isbn=978-0-309-37769-0 | doi=10.17226/21794 | page= | pmid=26803862 | editor-last1=Balogh | editor-last2=Miller | editor-last3=Ball | editor-first1=Erin P. | editor-first2=Bryan T. | editor-first3=John R. | last1=Balogh | first1=E. P. | last2=Miller | first2=B. T. | last3=Ball | first3=J. R. | author4=Committee on Diagnostic Error in Health Care | author5=Board on Health Care Services | author6=Institute of Medicine | author7=The National Academies of Sciences, Engineering, and Medicine }} This is the only definition that specifically includes the patient in the definition wording.

A prescription or medication error, as defined by the National Coordinating Council for Medication Error Reporting and Prevention, is an event that is preventable that leads to or has led to unsuitable use of medication or has led to harm to the person during the period of time that the medicine is controlled by a clinician, the person, or the consumer.{{Cite web |title=Medication Error Definition |url=https://www.nccmerp.org/about-medication-errors |access-date=2023-07-17 |website=National Coordinating Council for Medication Error Reporting and Prevention |archive-date=July 17, 2023 |archive-url=https://web.archive.org/web/20230717143129/https://www.nccmerp.org/about-medication-errors |url-status=live }} Some adverse drug events can also be related to medication errors.{{Cite journal |last1=Ciapponi |first1=Agustín |last2=Fernandez Nievas |first2=Simon E |last3=Seijo |first3=Mariana |last4=Rodríguez |first4=María Belén |last5=Vietto |first5=Valeria |last6=García-Perdomo |first6=Herney A |last7=Virgilio |first7=Sacha |last8=Fajreldines |first8=Ana V |last9=Tost |first9=Josep |last10=Rose |first10=Christopher J |last11=Garcia-Elorrio |first11=Ezequiel |date=2021-11-25 |title=Reducing medication errors for adults in hospital settings |journal=Cochrane Database of Systematic Reviews |language=en |volume=2021 |issue=11 |pages=CD009985 |doi=10.1002/14651858.CD009985.pub2 |pmc=8614640 |pmid=34822165}}

One extrapolation suggests that 180,000 people die each year partly as a result of iatrogenic injury.{{cite journal |author=Leape LL |year=1994 |title=Error in medicine |journal=JAMA |volume=272 |issue=23 |pages=1851–7 |doi=10.1001/jama.272.23.1851 |pmid=7503827}} The World Health Organization registered 14 million new cases and 8.2 million cancer-related deaths in 2012. It estimated that the number of cases could increase by 70% through 2032. As the number of cancer patients receiving treatment increases, hospitals around the world are seeking ways to improve patient safety, to emphasize traceability and raise efficiency in their cancer treatment processes.{{Cite web |title=Cancer |url=https://www.who.int/mediacentre/factsheets/fs297/en/ |access-date=2017-03-02 |website=World Health Organization |language=en-GB |archive-date=December 29, 2010 |archive-url=https://web.archive.org/web/20101229092321/http://www.who.int/mediacentre/factsheets/fs297/en/ |url-status=live }} Children are often more vulnerable to a negative outcome when a medication error occurs as they have age-related differences in how their bodies absorb, metabolize, and excrete pharmaceutical agents.

In the UK, an estimated 850,000 medical errors occur each year, costing over £2 billion (estimated in the year 2000).{{Cite journal |last=Donaldson |first=L |year=2000 |title=An organisation with a memory: Report of an expert group on learning from adverse events in the NHS |url=https://psnet.ahrq.gov/issue/organisation-memory-report-expert-group-learning-adverse-events-nhs-chaired-chief-medical |access-date=2023-07-17 |website=Patient Safety Network, UK |archive-date=July 17, 2023 |archive-url=https://web.archive.org/web/20230717152314/https://psnet.ahrq.gov/issue/organisation-memory-report-expert-group-learning-adverse-events-nhs-chaired-chief-medical |url-status=live }} The accuracy of this estimate is not clear. Criticism has included the statistical handling of measurement errors in the report,{{cite journal |last1=Hayward |first1=Rodney A. |last2=Heisler |first2=Michele |last3=Adams |first3=John |last4=Dudley |first4=R. Adams |last5=Hofer |first5=Timothy P. |title=Overestimating Outcome Rates: Statistical Estimation When Reliability Is Suboptimal |journal=Health Services Research |date=August 2007 |volume=42 |issue=4 |pages=1718–1738 |doi=10.1111/j.1475-6773.2006.00661.x |pmid=17610445 |pmc=1955272 }} and significant subjectivity in determining which deaths were "avoidable" or due to medical error, and an erroneous assumption that 100% of patients would have survived if optimal care had been provided.{{cite journal |vauthors=Hayward R, Hofer T |year=2001 |title=Estimating hospital deaths due to medical errors: preventability is in the eye of the reviewer |journal=JAMA |volume=286 |issue=4 |pages=415–20 |doi=10.1001/jama.286.4.415 |pmid=11466119}}

A 2006 study found that medication errors are among the most common medical mistakes, harming at least 1.5 million people every year. According to the study, 400,000 preventable drug-related injuries occur each year in hospitals, 800,000 in long-term care settings, and roughly 530,000 among Medicare recipients in outpatient clinics. The report stated that these are likely to be conservative estimates. In 2000 alone, the extra medical costs incurred by preventable drug-related injuries approximated $887 million{{mdash}}and the study looked only at injuries sustained by Medicare recipients, a subset of clinic visitors. None of these figures take into account lost wages and productivity or other costs.{{cite web |year=2006 |url=http://www8.nationalacademies.org/onpinews/newsitem.aspx?RecordID=11623 |title=Medication Errors Injure 1.5 Million People and Cost Billions of Dollars Annually |publisher=The National Academy of Science |access-date=February 1, 2011 |archive-date=November 26, 2015 |archive-url=https://web.archive.org/web/20151126062253/http://www8.nationalacademies.org/onpinews/newsitem.aspx?RecordID=11623 |url-status=live }}

According to a 2002 Agency for Healthcare Research and Quality report, about 7,000 people were estimated to die each year from medication errors – about 16 percent more deaths than the number attributable to work-related injuries (6,000 deaths).{{Citation needed|date=September 2011}} One in five Americans (22%) report that they or a family member have experienced a medical error of some kind.{{Cite web|url=http://www.commonwealthfund.org/about-us/annual-reports/2002-annual-report|archiveurl=https://web.archive.org/web/20180416064632/http://www.commonwealthfund.org/about-us/annual-reports/2002-annual-report|url-status=dead|title=2002 Annual Report|archivedate=April 16, 2018}} A 2000 Institute of Medicine report estimated that medical errors result in between 44,000 and 98,000 preventable deaths and 1,000,000 excess injuries each year in U.S. hospitals.{{cite journal |last1=Charatan |first1=Fred |date=4 March 2000 |title=Clinton acts to reduce medical mistakes |journal=BMJ |volume=320 |issue=7235 |pages=597 |doi=10.1136/bmj.320.7235.597 |pmc=1117638 |pmid=10698861}}{{cite journal |vauthors=Weingart SN, Wilson RM, Gibberd RW, Harrison B |date=March 2000 |title=Epidemiology of medical error |journal=BMJ |volume=320 |issue=7237 |pages=774–7 |doi=10.1136/bmj.320.7237.774 |pmc=1117772 |pmid=10720365}} A 2001 study in the Journal of the American Medical Association of seven Department of Veterans Affairs medical centers estimated that for roughly every 10,000 patients admitted to the select hospitals, one patient died who would have lived for three months or more in good cognitive health had "optimal" care been provided. A 2001 study estimated that 1% of hospital admissions result in an adverse event due to negligence.{{cite journal |doi=10.1056/NEJM199102073240604 |vauthors=Brennan T, Leape L, Laird N, Hebert L, Localio A, Lawthers A, Newhouse J, Weiler P, Hiatt H |title=Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I |journal=N Engl J Med |volume=324 |issue=6 |pages=370–6 |year=1991 |pmid=1987460 |s2cid=3101439 |doi-access=free }} Identification or errors may be a challenge in these studies, and mistakes may be more common than reported as these studies identify only mistakes that led to measurable adverse events occurring soon after the errors. Independent review of doctors' treatment plans suggests that decision-making could be improved in 14% of admissions; many of the benefits would have delayed manifestations.{{cite journal |vauthors=Lucas B, Evans A, Reilly B, Khodakov Y, Perumal K, Rohr L, Akamah J, Alausa T, Smith C, Smith J |title=The Impact of Evidence on Physicians' Inpatient Treatment Decisions |journal=J Gen Intern Med |volume=19 |issue=5 Pt 1 |pages=402–9 |year=2004 | doi = 10.1111/j.1525-1497.2004.30306.x | pmid=15109337 |pmc=1492243}} Even this number may be an underestimate. One study suggests that adults in the United States receive only 55% of recommended care.{{cite journal |vauthors=McGlynn EA, Asch SM, Adams J, Keesey J, Hicks J, DeCristofaro A, Kerr EA | year = 2003 | title = The quality of health care delivered to adults in the United States | journal = N Engl J Med | volume = 348 | issue = 26| pages = 2635–45 | doi = 10.1056/NEJMsa022615 | pmid = 12826639 | doi-access = free }} At the same time, a second study found that 30% of care in the United States may be unnecessary.{{cite journal | pmid = 14573739 | doi=10.1056/NEJMe038149 | volume=349 | issue=17 | journal = New England Journal of Medicine |date=October 2003 | title = Medical Care — Is More Always Better? | pages=1665–7 |vauthors=Fisher ES}} For example, if a doctor fails to order a mammogram that is past due, this mistake will not show up in the first type of study. In addition, because no adverse event occurred during the short follow-up of the study, the mistake also would not show up in the second type of study because only the principal treatment plans were critiqued. However, the mistake would be recorded in the third type of study. If a doctor recommends an unnecessary treatment or test, it may not show in any of these types of studies.

Cause of death on United States death certificates, statistically compiled by the Centers for Disease Control and Prevention (CDC), are coded in the International Classification of Disease (ICD), which does not include codes for human and system factors.{{cite journal |last1=Makary |first1=Martin A |last2=Daniel |first2=Michael |title=Medical error—the third leading cause of death in the US |journal=BMJ |volume=353 |date=3 May 2016 |pages=i2139 |doi=10.1136/bmj.i2139 |pmid=27143499 |s2cid=206910205 }}{{cite book|last1=Moriyama|first1=IM|last2=Loy|first2=RM|last3=Robb-Smith|first3=AHT|editor1-last=Rosenberg|editor1-first=HM|editor2-last=Hoyert|editor2-first=DL|title=History of the Statistical Classification of Diseases and Causes of Death|date=2011|publisher=U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics|location=Hyattsville, MD|isbn=978-0-8406-0644-0|url=https://www.cdc.gov/nchs/data/misc/classification_diseases2011.pdf|access-date=September 10, 2017|archive-date=May 5, 2011|archive-url=https://web.archive.org/web/20110505192204/http://www.cdc.gov/nchs/data/misc/classification_diseases2011.pdf|url-status=live}}

{{See also|Healthcare error proliferation model}}

The research literature showed that medical errors are caused by errors of commission and errors of omission.{{Cite journal|last1=Clapper|first1=Timothy C.|last2=Ching|first2=Kevin|year=2020|title=Debunking the myth that the majority of medical errors are attributed to communication|journal=Medical Education|language=en|volume=54|issue=1|pages=74–81|doi=10.1111/medu.13821|pmid=31509277|issn=1365-2923|doi-access=free}} Errors of omission are made when providers did not take action when they should have, while errors of commission occur when decisions and action are delayed. A special form of an error of commission occurs when health care professionals commit to unnecessary treatment in the case of Medical child abuse (Munchausen syndrome by proxy). Commission and omission errors have also been attributed with communication failures.{{Cite book|last1=Hannawa|first1=Annegret|url=https://www.degruyter.com/document/doi/10.1515/9783110454857/html|title=New Horizons in Patient Safety: Safe Communication: Evidence-based core Competencies with Case Studies from Nursing Practice|last2=Wendt|first2=Anne|last3=Day|first3=Lisa J.|date=2017-12-04|publisher=De Gruyter|isbn=978-3-11-045485-7|doi=10.1515/9783110454857|access-date=April 21, 2021|archive-date=April 21, 2021|archive-url=https://web.archive.org/web/20210421212531/https://www.degruyter.com/document/doi/10.1515/9783110454857/html|url-status=live}}{{Cite book|last1=Hannawa|first1=Annegret|url=https://www.degruyter.com/document/doi/10.1515/9783110455014/html|title=New Horizons in Patient Safety: Understanding Communication: Case Studies for Physicians|last2=Wu|first2=Albert|last3=Juhasz|first3=Robert|date=2017-03-06|publisher=De Gruyter|isbn=978-3-11-045501-4|doi=10.1515/9783110455014|access-date=April 21, 2021|archive-date=August 14, 2024|archive-url=https://web.archive.org/web/20240814204244/https://www.degruyter.com/document/doi/10.1515/9783110455014/html|url-status=live}}

A study with data from 67 826 patients found that poor communication was the only identifiable cause of 1 in 10 patient safety incidents, and that poor communication contributes to 25% of patient safety incidents.{{cite journal |last1=Keshtkar |first1=L |last2=Bennett-Weston |first2=A |last3=Khan |first3=AS |last4=Mohan |first4=S |last5=Jones |first5=M |last6=Nockels |first6=K |last7=Gunn |first7=S |last8=Armstrong |first8=N |last9=Bostock |first9=J |last10=Howick |first10=J |title=Impacts of Communication Type and Quality on Patient Safety Incidents: A Systematic Review |journal=Annals of Internal Medicine |date=15 April 2025 |doi=10.7326/ANNALS-24-02904 |pmid=40228297}}

Medical errors can be associated with inexperienced physicians and nurses, new procedures, extremes of age, and complex or urgent care.{{cite journal |last1=Harrison |first1=Bernadette |last2=Gibberd |first2=Robert W. |last3=Wilson |first3=Ross McL |last4=Weingart |first4=N. Saul |title=Epidemiology of medical error |journal=BMJ |date=18 March 2000 |volume=320 |issue=7237 |pages=774–777 |doi=10.1136/bmj.320.7237.774 |pmid=10720365 |pmc=1117772 }} Poor communication (whether in one's own language or, as may be the case for medical tourists, another language), improper documentation, illegible handwriting, spelling errors, inadequate nurse-to-patient ratios, and similarly named medications are also known to contribute to the problem.{{cite web |last1=Friedman |first1=Richard A. |last2=D |first2=M |year=2003 |url=https://www.nytimes.com/2003/03/11/health/cases-do-spelling-and-penmanship-count-in-medicine-you-bet.html |title=CASES; Do Spelling and Penmanship Count? In Medicine, You Bet |work=The New York Times |access-date=2018-08-29 |archive-date=August 29, 2019 |archive-url=https://web.archive.org/web/20190829071131/https://www.nytimes.com/2003/03/11/health/cases-do-spelling-and-penmanship-count-in-medicine-you-bet.html |url-status=live }}{{Cite journal|last=Hannawa|first=Annegret F|date=June 2018|title="SACCIA Safe Communication": Five core competencies for safe and high-quality care|url=http://journals.sagepub.com/doi/10.1177/2516043518774445|journal=Journal of Patient Safety and Risk Management|language=en|volume=23|issue=3|pages=99–107|doi=10.1177/2516043518774445|s2cid=169364817|issn=2516-0435|access-date=April 21, 2021|archive-date=April 23, 2021|archive-url=https://web.archive.org/web/20210423104013/https://journals.sagepub.com/doi/10.1177/2516043518774445|url-status=live}} Misdiagnosis may be associated with individual characteristics of the patient or due to the patient multimorbidity.{{Cite journal|last1=Lyundup|first1=Alexey V.|last2=Balyasin|first2=Maxim V.|last3=Maksimova|first3=Nadezhda V.|last4=Kovina|first4=Marina V.|last5=Krasheninnikov|first5=Mikhail E.|last6=Dyuzheva|first6=Tatiana G.|last7=Yakovenko|first7=Sergey A.|last8=Appolonova|first8=Svetlana A.|last9=Schiöth|first9=Helgi B.|last10=Klabukov|first10=Ilya D.|date=2021-10-29|title=Misdiagnosis of diabetic foot ulcer in patients with undiagnosed skin malignancies|journal=International Wound Journal|volume=19 |issue=4 |pages=871–887 |doi=10.1111/iwj.13688|issn=1742-481X|pmid=34713964|pmc=9013580 |s2cid=240154096}}{{Cite journal|last1=Aoki|first1=Takuya|last2=Watanuki|first2=Satoshi|date=2020-08-20|title=Multimorbidity and patient-reported diagnostic errors in the primary care setting: multicentre cross-sectional study in Japan|journal=BMJ Open|volume=10|issue=8|pages=e039040|doi=10.1136/bmjopen-2020-039040|issn=2044-6055|pmc=7440713|pmid=32819954}} Patient actions or inactions may also contribute significantly to medical errors.

Complicated technologies,{{cite journal |last1=Maskell |first1=Giles |title=Error in radiology—where are we now? |journal=The British Journal of Radiology |year=2019 |volume=92 |issue=1096 |pages=20180845 |doi=10.1259/bjr.20180845|pmid=30457880 |pmc=6540865 }}{{cite journal |last1=McGurk |first1=S |last2=Brauer |first2=K |last3=Macfarlane |first3=TV |last4=Duncan |first4=KA |title=The effect of voice recognition software on comparative error rates in radiology reports |journal=Br J Radiol |year=2008|volume=81 |issue=970 |pages=767–70 |doi=10.1259/bjr/20698753 |pmid=18628322 }} powerful drugs, intensive care, rare and multiple diseases,{{cite journal|author1=Wadhwa, R. R.|author2=Park, D. Y.|author3=Natowicz, M. R.|title=The accuracy of computer-based diagnostic tools for the identification of concurrent genetic disorders|journal=American Journal of Medical Genetics Part A|volume=176|issue=12|pages=2704–2709|doi=10.1002/ajmg.a.40651|pmid=30475443|year=2018|s2cid=53758271}} and prolonged hospital stay can contribute to medical errors.{{cite journal | vauthors = Weingart SN | title = Epidemiology of medical error | journal = Western Journal of Medicine | date=June 2000 | volume = 172 | issue = 6 | pages = 390–3 | doi = 10.1136/ewjm.172.6.390 | pmid = 10854389| pmc = 1070928 }} In turn, medical errors from carelessness or improper use of medical devices often lead to severe injuries or death. Since 2015, 60 injuries and 23 deaths have been caused by misplaced feeding tubes while using the Cortrak2 EAS system. The FDA recalled Avanos Medical's Cortrak system in 2022 due to its severity and the high toll associated with the medical error.{{cite web |title=Feeding Tube Placement Devices Recalled After 23 Patient Deaths |url=https://www.schmidtlaw.com/feeding-tube-placement-devices-recalled-after-23-patient-deaths/ |website=schmidtlaw.com |access-date=February 13, 2023 |archive-date=February 13, 2023 |archive-url=https://web.archive.org/web/20230213205711/https://www.schmidtlaw.com/feeding-tube-placement-devices-recalled-after-23-patient-deaths/ |url-status=live }}

Complexity makes diagnosis especially challenging. There are less than 200 symptoms listed in Wikipedia,List of medical symptoms.

https://en.wikipedia.org/wiki/List_of_medical_symptoms#Medical_signs_and_symptoms {{Webarchive|url=https://web.archive.org/web/20220126155958/https://en.wikipedia.org/wiki/List_of_medical_symptoms#Medical_signs_and_symptoms |date=January 26, 2022 }} but there are probably more than 10,000 known diseases. The World Health Organization's system for the International Classification of Disease, 9th Edition from 1979 listed over 14,000 diagnosis codes.{{cite journal | last1=Utter | first1=Garth H. | last2=Atolagbe | first2=Oluseun O. | last3=Cooke | first3=David T. | title=The Use of the International Classification of Diseases, Tenth Revision, Clinical Modification and Procedure Classification System in Clinical and Health Services Research: The Devil Is in the Details | journal=JAMA Surgery | volume=154 | issue=12 | date=2019-12-01 | issn=2168-6262 | pmid=31553423 | doi=10.1001/jamasurg.2019.2899 | pages=1089–1090}} Textbooks of medicine often describe the most typical presentations of a disease, but in many conditions patients may have variable presentations instead of the classical signs and symptoms. To add complexity, the signs and symptoms of a given condition change over time; in the early stages the signs and symptoms may be absent or minimal, and then these evolve as the condition progresses. Diagnosis is often challenging in infants and children who can't clearly communicate their symptoms, and in the elderly, where signs and symptoms may be muted or absent.{{cite journal | last=Emmett | first=K. R. | title=Nonspecific and atypical presentation of disease in the older patient | journal=Geriatrics | volume=53 | issue=2 |year=1998 | issn=0016-867X | pmid=9484285 | pages=50–52, 58–60}}

There are more than 7000 rare diseases alone, and in aggregate these are not uncommon: Roughly 1 in 17 patients will be diagnosed with a rare disease over their lifetime.{{cite journal | last1=Ronicke | first1=Simon | last2=Hirsch | first2=Martin C. | last3=Türk | first3=Ewelina | last4=Larionov | first4=Katharina | last5=Tientcheu | first5=Daphne | last6=Wagner | first6=Annette D. | title=Can a decision support system accelerate rare disease diagnosis? Evaluating the potential impact of Ada DX in a retrospective study | journal=Orphanet Journal of Rare Diseases | volume=14 | issue=1 | date=2019-03-21 | issn=1750-1172 | pmid=30898118 | pmc=6427854 | doi=10.1186/s13023-019-1040-6 | doi-access=free | page=69}} Physicians may have only learned a handful of these during their education and training.

In 2000, The Institute of Medicine released "To Err is Human," which asserted that the problem in medical errors is not bad people in health care—it is that good people are working in bad systems that need to be made safer.

Poor communication and unclear lines of authority of physicians, nurses, and other care providers are also contributing factors. Disconnected reporting systems within a hospital can result in fragmented systems in which numerous hand-offs of patients results in lack of coordination and errors.{{cite news |last=Gardner |first=Amanda |date=6 March 2007 |url=https://www.washingtonpost.com/wp-dyn/content/article/2007/03/06/AR2007030601334.html |title=Medication Errors During Surgeries Particularly Dangerous |newspaper=The Washington Post |access-date=2007-03-13 |archive-date=July 15, 2018 |archive-url=https://web.archive.org/web/20180715075937/http://www.washingtonpost.com/wp-dyn/content/article/2007/03/06/AR2007030601334.html |url-status=live }}

Other factors include the impression that action is being taken by other groups within the institution, reliance on automated systems to prevent error.,{{cite journal |last=McDonald, MD |first=Clement J. |title=Computerization Can Create Safety Hazards: A Bar-Coding Near Miss |journal=Annals of Internal Medicine |volume=144 |issue=7 |pages=510–516 |date=4 April 2006 |pmid=16585665 |doi=10.7326/0003-4819-144-7-200604040-00010|doi-access=free }} and inadequate systems to share information about errors, which hampers analysis of contributory causes and improvement strategies.{{cite web |last=US Agency for Healthcare Research & Quality |date=2008-01-09 |url=http://www.ahrq.gov/news/press/pr2008/errepsyspr.htm |title=Physicians Want To Learn from Medical Mistakes but Say Current Error-reporting Systems Are Inadequate |access-date=2008-03-23 |url-status=dead |archive-url=https://web.archive.org/web/20080217054943/http://www.ahrq.gov/news/press/pr2008/errepsyspr.htm |archive-date=2008-02-17 }}

Cost-cutting measures by hospitals in response to reimbursement cutbacks can compromise patient safety.{{cite journal |author1=Clement JP |author2=Lindrooth RC |author3=Chukmaitov AS |author4=Chen HF |title=Does the patient's payer matter in hospital patient safety?: a study of urban hospitals |journal=Med Care |volume=45 |issue=2 |pages=131–8 |date=February 2007 |pmid=17224775 |doi=10.1097/01.mlr.0000244636.54588.2b|s2cid=22206854 }}

In emergencies, patient care may be rendered in areas poorly suited for safe monitoring. The American Institute of Architects has identified concerns for the safe design and construction of health care facilities.{{cite journal |journal=The American Institute of Architects Academy Journal |title=Incorporating Patient-Safe Design into the Guidelines |date=2005-10-19 |url=http://www.aia.org/journal_aah.cfm?pagename=aah_jrnl_20051019_guidelines&dspl=1&article=article |access-date=August 11, 2010 |archive-date=October 7, 2006 |archive-url=https://web.archive.org/web/20061007082132/http://www.aia.org/journal_aah.cfm?pagename=aah_jrnl_20051019_guidelines |url-status=dead }}

Infrastructure failure is also a concern. According to the WHO, 50% of medical equipment in developing countries is only partly usable due to lack of skilled operators or parts. As a result, diagnostic procedures or treatments cannot be performed, leading to substandard treatment.

The Joint Commission's Annual Report on Quality and Safety 2007 found that inadequate communication between healthcare providers, or between providers and the patient and family members, was the root cause of over half the serious adverse events in accredited hospitals.{{Cite web |url=http://www.jointcommissionreport.org/ |title=Improving America's Hospitals |access-date=August 11, 2010 |archive-date=April 16, 2008 |archive-url=https://web.archive.org/web/20080416205706/http://www.jointcommissionreport.org/ |url-status=live }} Other leading causes included inadequate assessment of the patient's condition, and poor leadership or training.

Variations in healthcare provider training & experience{{cite journal |last1=Neale |first1=Graham |last2=Woloshynowych |first2=Maria |last3=Vincent |first3=Charles |title=Exploring the causes of adverse events in NHS hospital practice |journal=Journal of the Royal Society of Medicine |volume=94 |issue=7 |pages=322–30 |date=July 2001 |pmc=1281594 |pmid=11418700|doi=10.1177/014107680109400702 }} and failure to acknowledge the prevalence and seriousness of medical errors also increase the risk.{{cite journal |author=Michael L. Millenson |year=2003 |title=The Silence |journal=Health Affairs |volume=22 |pages=103–112 |doi=10.1377/hlthaff.22.2.103 |pmid=12674412 |issue=2|s2cid=40037135 }}{{cite journal |last=Henneman |first=Elizabeth A. |date=1 October 2007 |title=Unreported Errors in the Intensive Care Unit, A Case Study of the Way We Work |journal=Critical Care Nurse |volume=27 |pages=27–34 |url=http://ccn.aacnjournals.org/cgi/content/full/27/5/27 |access-date=2008-03-23 |pmid=17901458 |issue=5 |doi=10.4037/ccn2007.27.5.27 |archive-date=October 13, 2008 |archive-url=https://web.archive.org/web/20081013050913/http://ccn.aacnjournals.org/cgi/content/full/27/5/27 |url-status=live }} The so-called July effect occurs when new residents arrive at teaching hospitals, causing an increase in medication errors according to a study of data from 1979 to 2006.{{cite journal |author1=Phillips DP |author2=Barker GE |title=A July Spike in Fatal Medication Errors: A Possible Effect of New Medical Residents |journal=J Gen Intern Med |volume=25 |issue=8 |pages=774–779|date=May 2010 |pmid=20512532 |doi=10.1007/s11606-010-1356-3 |pmc=2896592}}{{cite journal |last1=Krupa |first1=Carolyne |title=New residents linked to July medication errors |journal=American Medical News |date=21 June 2010 |volume=6 |issue=21 |url=https://insights.ovid.com/american-medical-news/ammn/2010/06/210/new-residents-linked-july-medication-errors/14/00000476 |access-date=September 8, 2019 |archive-date=October 21, 2020 |archive-url=https://web.archive.org/web/20201021103522/https://insights.ovid.com/american-medical-news/ammn/2010/06/210/new-residents-linked-july-medication-errors/14/00000476 |url-status=live }}

File:Okunuşu,yazılışı yakın ilaçlar.jpg

Cognitive errors commonly encountered in medicine were initially identified by psychologists Amos Tversky and Daniel Kahneman in the early 1970s. Jerome Groopman, author of How Doctors Think, says these are "cognitive pitfalls", biases which cloud our logic. For example, a practitioner may overvalue the first data encountered, skewing their thinking. Another example may be where the practitioner recalls a recent or dramatic case that quickly comes to mind, coloring the practitioner's judgement. Another pitfall is where stereotypes may prejudice thinking.{{cite magazine |url=http://www.nybooks.com/articles/archives/2009/nov/05/diagnosis-what-doctors-are-missing/ |title=Diagnosis: What Doctors are Missing |author=Jerome E. Groopman |date=5 November 2009 |magazine=New York Review of Books |author-link=Jerome E. Groopman |access-date=July 9, 2014 |archive-date=September 17, 2015 |archive-url=https://web.archive.org/web/20150917174143/http://www.nybooks.com/articles/archives/2009/nov/05/diagnosis-what-doctors-are-missing/ |url-status=live }} Pat Croskerry describes clinical reasoning as an interplay between intuitive, subconscious thought (System 1) and deliberate, conscious rational consideration (System 2). In this framework, many cognitive errors reflect over-reliance on System 1 processing, although cognitive errors may also sometimes involve System 2.{{cite journal |last1=Croskerry |first1=P. |year=2009 |title=A Universal Model of Clinical Reasoning |journal=Acad Med |volume=84 |issue=8 |pages=1022–8 |doi=10.1097/ACM.0b013e3181ace703 |pmid=19638766 |doi-access=free}}

Sleep deprivation has also been cited as a contributing factor in medical errors.{{cite journal |last1=Ker |first1=Katharine |last2=Edwards |first2=Philip James |last3=Felix |first3=Lambert M |last4=Blackhall |first4=Karen |last5=Roberts |first5=Ian |date=12 May 2010 |title=Caffeine for the prevention of injuries and errors in shift workers |journal=Cochrane Database of Systematic Reviews |volume=2010 |issue=5 |pages=CD008508 |doi=10.1002/14651858.CD008508 |pmc=4160007 |pmid=20464765}} One study found that being awake for over 24 hours caused medical interns to double or triple the number of preventable medical errors, including those that resulted in injury or death.{{cite journal |last1=Barger |first1=L. K. |last2=Ayas |first2=N. T. |last3=Cade |first3=B. E. |last4=Cronin |first4=J. W. |last5=Rosner |first5=B. |last6=Speizer |first6=F. E. |last7=Czeisler |first7=C. A. |display-authors=1 |year=2006 |title=Impact of Extended-Duration Shifts on Medical Errors, Adverse Events, and Attentional Failures |journal=PLOS Med |volume=3 |issue=12 |page=e487 |doi=10.1371/journal.pmed.0030487 |pmc=1705824 |pmid=17194188 |doi-access=free }} The risk of car crash after these shifts increased by 168%, and the risk of near miss by 460%.{{Cite web |url=https://www.npr.org/templates/story/story.php?storyId=6619687 |title=When Doctors Don't Sleep |website=NPR |access-date=April 3, 2018 |archive-date=May 9, 2021 |archive-url=https://web.archive.org/web/20210509151219/https://www.npr.org/templates/story/story.php?storyId=6619687 |url-status=live }} Interns admitted falling asleep during lectures, during rounds, and even during surgeries. Night shifts are associated with worse surgeon performance during laparoscopic surgeries.

Practitioner risk factors include fatigue,{{cite journal |last1=Nocera |first1=Antony |last2=Khursandi |first2=Diana Strange |title=Doctors' working hours: can the medical profession afford to let the courts decide what is reasonable? |journal=Medical Journal of Australia |date=June 1998 |volume=168 |issue=12 |pages=616–618 |doi=10.5694/j.1326-5377.1998.tb141450.x |pmid=9673625 |s2cid=34759813 }}{{cite journal |last1=Landrigan |first1=Christopher P. |last2=Rothschild |first2=Jeffrey M. |last3=Cronin |first3=John W. |last4=Kaushal |first4=Rainu |last5=Burdick |first5=Elisabeth |last6=Katz |first6=Joel T. |last7=Lilly |first7=Craig M. |last8=Stone |first8=Peter H. |last9=Lockley |first9=Steven W. |last10=Bates |first10=David W. |last11=Czeisler |first11=Charles A. |title=Effect of Reducing Interns' Work Hours on Serious Medical Errors in Intensive Care Units |journal=New England Journal of Medicine |date=28 October 2004 |volume=351 |issue=18 |pages=1838–1848 |doi=10.1056/NEJMoa041406 |pmid=15509817 |doi-access=free }}{{cite journal |last1=Barger |first1=Laura K |last2=Ayas |first2=Najib T |last3=Cade |first3=Brian E |last4=Cronin |first4=John W |last5=Rosner |first5=Bernard |last6=Speizer |first6=Frank E |last7=Czeisler |first7=Charles A |last8=Mignot |first8=Emmanuel |title=Impact of Extended-Duration Shifts on Medical Errors, Adverse Events, and Attentional Failures |journal=PLOS Medicine |date=12 December 2006 |volume=3 |issue=12 |pages=e487 |doi=10.1371/journal.pmed.0030487 |pmid=17194188 |pmc=1705824 |doi-access=free }}

depression,{{cite journal |last1=Pereira-Lima |first1=K |last2=Mata |first2=DA |last3=Loureiro |first3=SR |last4=Crippa |first4=JA |last5=Bolsoni |first5=LM |last6=Sen |first6=S |year=2019 |title=Association Between Physician Depressive Symptoms and Medical Errors: A Systematic Review and Meta-analysis |journal=JAMA Network Open |volume=2 |issue=11 |pages=e1916097 |doi=10.1001/jamanetworkopen.2019.16097 |pmid=31774520 |pmc=6902829 }} and burnout.{{cite journal |last1=Fahrenkopf |first1=Amy M |last2=Sectish |first2=Theodore C |last3=Barger |first3=Laura K |last4=Sharek |first4=Paul J |last5=Lewin |first5=Daniel |last6=Chiang |first6=Vincent W |last7=Edwards |first7=Sarah |last8=Wiedermann |first8=Bernhard L |last9=Landrigan |first9=Christopher P |title=Rates of medication errors among depressed and burnt out residents: prospective cohort study |journal=BMJ |date=1 March 2008 |volume=336 |issue=7642 |pages=488–491 |doi=10.1136/bmj.39469.763218.BE |pmid=18258931 |pmc=2258399 }}

Factors related to the clinical setting include diverse patients, unfamiliar settings, time pressures, and increased patient-to-nurse staffing ratio increases.{{cite journal |last1=Aiken |first1=Linda H. |last2=Clarke |first2=SP |last3=Sloane |first3=DM |last4=Sochalski |first4=J |last5=Silber |first5=JH |title=Hospital Nurse Staffing and Patient Mortality, Nurse Burnout, and Job Dissatisfaction |journal=JAMA |date=23 October 2002 |volume=288 |issue=16 |pages=1987–93 |doi=10.1001/jama.288.16.1987 |pmid=12387650 |doi-access=free }}

Drug names that look alike or sound alike are also a problem.{{cite web | last=8th Annual MEDMARX Report | date=2008-01-29 | url=http://www.usp.org/aboutUSP/media/newsCenter.html?article=105435 | title=Press Release | publisher=U.S. Pharmacopeia | access-date=2008-03-23 | url-status=dead | archive-url=https://archive.today/20080208093723/http://www.usp.org/aboutUSP/media/newsCenter.html?article=105435 | archive-date=2008-02-08 }}

Errors in interpreting medical images are often perceptual instead of "fact-based"; these errors are often caused by failures of attention or vision.{{cite journal |last1=Waite |first1=Stephen |last2=Grigorian |first2=Arkadij |last3=Alexander |first3=Robert G. |last4=Macknik |first4=Stephen L. |last5=Carrasco |first5=Marisa |last6=Heeger |first6=David J. |last7=Martinez-Conde |first7=Susana |title=Analysis of Perceptual Expertise in Radiology – Current Knowledge and a New Perspective |journal=Frontiers in Human Neuroscience |date=25 June 2019 |volume=13 |pages=213 |doi=10.3389/fnhum.2019.00213 |pmid=31293407 |pmc=6603246 |doi-access=free }} For example, visual illusions can cause radiologists to misperceive images.{{cite journal |last1=Alexander |first1=Robert |last2=Yazdanie |first2=Fahd |last3=Waite |first3=Stephen Anthony |last4=Chaudhry |first4=Zeshan |last5=Kolla |first5=Srinivas |last6=Macknik |first6=Stephen |last7=Martinez-Conde |first7=Susana |title=Visual Illusions in Radiology: untrue perceptions in medical images and their implications for diagnostic accuracy |journal=Frontiers in Neuroscience |year=2021 |volume=15 |page=629469 |doi=10.3389/fnins.2021.629469|pmid=34177444 |pmc=8226024 |doi-access=free }}

A number of Information Technology (IT) systems have been developed to detect and prevent medication errors, the most common type of medical errors.{{Cite book|last=Anderson|first=J.G.|title=Information technology for detecting medication errors and adverse drug events. (Expert Opin Drug Saf 3)|year=2005|pages=449–455}} These systems screen data such as ICD-9 codes, pharmacy and laboratory data. Rules are used to look for changes in medication orders, and abnormal laboratory results that may be indicative of medication errors and/or adverse drug events.{{Cite journal|last1=Abrahamson|first1=Kathleen|last2=Anderson|first2=J.G.|year=2017|title=Your Health Care May Kill You: Medical Errors|journal=Studies in Health Technology and Informatics|volume=234|issue=Building Capacity for Health Informatics in the Future|pages=13–17|doi=10.3233/978-1-61499-742-9-13|pmid=28186008|url=https://ebooks.iospress.nl/publication/46132|access-date=September 2, 2021|archive-date=September 2, 2021|archive-url=https://web.archive.org/web/20210902215631/https://ebooks.iospress.nl/publication/46132|url-status=live}}

Errors can include misdiagnosis or delayed diagnosis, administration of the wrong drug to the wrong patient or in the wrong way, giving multiple drugs that interact negatively, surgery on an incorrect site, failure to remove all surgical instruments, failure to take the correct blood type into account, or incorrect record-keeping. A 10th type of error is ones which are not watched for by researchers, such as RNs failing to program an IV pump to give a full dose of IV antibiotics or other medication.

The projected cost of medical errors to the U.S. economy is approximately $20 billion, 87% of which are direct increases in medical costs of providing services to patient affected by medical errors.{{Cite web|url=https://www.soa.org/globalassets/assets/files/research/projects/research-econ-measurement.pdf|title=The Economic Measurement of Medical Errors|last=Shreve|first=J et al (Milliman Inc.)|date=June 2010|website=Society of Actuaries|access-date=November 11, 2019|archive-date=January 15, 2021|archive-url=https://web.archive.org/web/20210115165754/https://www.soa.org/globalassets/assets/Files/Research/Projects/research-econ-measurement.pdf|url-status=live}} Medical errors can increase average hospital costs by as much as $4,769 per patient.{{Cite journal|last=Arlen|first=Jennifer|date=October 1, 2013|title=Economic Analysis of Medical Malpractice Liability and Its Reform|journal=New York University Law and Economics Working Papers|ssrn=2262792}} One common type of medical error stems from x-rays and medical imaging: failing to see or notice signs of disease on an image. The retrospective "miss" rate among abnormal imaging studies is reported to be as high as 30% (the real-life error rate is much lower, around 4-5%, because not all images are abnormal),{{cite journal |last1=Berlin |first1=Leonard |title=Accuracy of Diagnostic Procedures: Has It Improved Over the Past Five Decades? |journal=American Journal of Roentgenology |year= 2007 |volume=188 |issue=5 |pages=1173–1178 |doi=10.2214/AJR.06.1270|pmid=17449754 }} and up to 20% of missed findings result in long-term adverse effects.{{Cite journal|last=Brady|first=Adrian|date=December 7, 2016|title=Error and discrepancy in radiology: inevitable or avoidable?|journal=Insights into Imaging|volume=8|issue=1|pages=171–182|doi=10.1007/s13244-016-0534-1|pmid=27928712|pmc=5265198|doi-access=free}}{{Cite journal|last=Brady|first=Adrian|date=January 2012|title=Discrepancy and Error in Radiology: Concepts, Causes and Consequences|journal=Ulster Med J.|volume=81|issue=1|pages=3–9|pmc=3609674|pmid=23536732}}

A large study reported several cases where patients were wrongly told that they were HIV-negative when the physicians erroneously ordered and interpreted HTLV (a closely related virus) testing rather than HIV testing. In the same study, >90% of HTLV tests were ordered erroneously.{{cite journal |last=Siemieniuk |first=Reed |author2=Fonseca, Kevin |author3=Gill, M. John |title=Using Root Cause Analysis and Form Redesign to Reduce Incorrect Ordering of HIV Tests |journal=Joint Commission Journal on Quality and Patient Safety |date=November 2012 |volume=38 |issue=11 |pages=506–512 |pmid=23173397 |doi=10.1016/S1553-7250(12)38067-7 }}

A 2008 literature review in The American Journal of Medicine estimated that between 10 and 15% of physician diagnoses are erroneous.{{cite journal |last1=Berner |first1=Eta S. |last2=Graber |first2=Mark L. |title=Overconfidence as a Cause of Diagnostic Error in Medicine |journal=The American Journal of Medicine |date=May 2008 |volume=121 |issue=5 |pages=S2–S23 |doi=10.1016/j.amjmed.2008.01.001 |pmid=18440350 |doi-access=free }}

Misdiagnosis of lower extremity cellulitis is estimated to occur in 30% of patients, leading to unnecessary hospitalizations in 85% and unnecessary antibiotic use in 92%. Collectively, these errors lead to between 50,000 and 130,000 unnecessary hospitalizations and between $195 and $515 million in avoidable health care spending annually in the United States.{{cite journal |last1=Weng |first1=Qing Yu |last2=Raff |first2=Adam B. |last3=Cohen |first3=Jeffrey M. |last4=Gunasekera |first4=Nicole |last5=Okhovat |first5=Jean-Phillip |last6=Vedak |first6=Priyanka |last7=Joyce |first7=Cara |last8=Kroshinsky |first8=Daniela |last9=Mostaghimi |first9=Arash |title=Costs and Consequences Associated With Misdiagnosed Lower Extremity Cellulitis |journal=JAMA Dermatology |date=1 February 2017 |volume=153 |issue=2 |pages=141–146 |doi=10.1001/jamadermatol.2016.3816 |pmid=27806170 |s2cid=205110504 |url=http://nrs.harvard.edu/urn-3:HUL.InstRepos:33785925 |access-date=September 8, 2019 |archive-date=August 14, 2024 |archive-url=https://web.archive.org/web/20240814204252/https://dash.harvard.edu/handle/1/33785925 |url-status=live }}

Female sexual desire sometimes used to be diagnosed as female hysteria.{{citation needed|date=June 2015}}

Sensitivities to foods and food allergies risk being misdiagnosed as the anxiety disorder orthorexia.

Studies have found that bipolar disorder has often been misdiagnosed as major depression. Its early diagnosis necessitates that clinicians pay attention to the features of the patient's depression and also look for present or prior hypomanic or manic symptomatology.{{cite journal |last1=Bowden |first1=Charles L. |title=Strategies to Reduce Misdiagnosis of Bipolar Depression |journal=Psychiatric Services |date=January 2001 |volume=52 |issue=1 |pages=51–55 |doi=10.1176/appi.ps.52.1.51 |pmid=11141528 }}

The misdiagnosis of schizophrenia is also a common problem. There may be long delays of patients getting a correct diagnosis of this disorder.{{cite news |title=Schizophrenia Symptoms |publisher=schizophrenia.com |access-date=2008-03-30 |url=http://www.schizophrenia.com/diag.php |archive-date=December 5, 2015 |archive-url=https://web.archive.org/web/20151205115712/http://schizophrenia.com/diag.php |url-status=live }}

Delayed sleep phase disorder is often confused with: psychophysiological insomnia; depression; psychiatric disorders such as schizophrenia, ADHD or ADD; other sleep disorders; or school refusal. Practitioners of sleep medicine point out the dismally low rate of accurate diagnosis of the disorder, and have often asked for better physician education on sleep disorders.{{cite journal |vauthors=Dagan Y, Ayalon L |title=Case study: psychiatric misdiagnosis of non-24-hours sleep–wake schedule disorder resolved by melatonin |journal=J Am Acad Child Adolesc Psychiatry |volume=44 |issue=12 |pages=1271–1275 |year=2005 |pmid=16292119 |doi= 10.1097/01.chi.0000181040.83465.48}}

Cluster headaches are often misdiagnosed, mismanaged, or undiagnosed for many years; they may be confused with migraine, "cluster-like" headache (or mimics), CH subtypes, other TACs ( trigeminal autonomic cephalalgias), or other types of primary or secondary headache syndrome.{{cite journal |last1=van Vliet |first1=J A |last2=Eekers |first2=PJ |last3=Haan |first3=J |last4=Ferrari |first4=MD |last5=Dutch RUSSH Study |first5=Group. |title=Features involved in the diagnostic delay of cluster headache |journal=Journal of Neurology, Neurosurgery & Psychiatry |date=1 August 2003 |volume=74 |issue=8 |pages=1123–1125 |doi=10.1136/jnnp.74.8.1123 |pmid=12876249 |pmc=1738593 }} Cluster-like head pain may be diagnosed as secondary headache rather than cluster headache.{{cite web |url= http://www.ihs-classification.org/en/02_klassifikation/02_teil1/03.01.00_cluster.html |title= IHS Classification ICHD-II 3.1 Cluster headache |publisher= The International Headache Society |access-date= 2014-01-03 |url-status= dead |archive-url= https://web.archive.org/web/20131103182003/http://www.ihs-classification.org/en/02_klassifikation/02_teil1/03.01.00_cluster.html |archive-date= 3 November 2013 |df= dmy-all }} Under-recognition of CH by health care professionals is reflected in consistent findings in Europe and the United States that the average time to diagnosis is around seven years.{{cite journal |last1=Tfelt-Hansen |first1=Peer C. |last2=Jensen |first2=Rigmor H. |title=Management of Cluster Headache |journal=CNS Drugs |date=July 2012 |volume=26 |issue=7 |pages=571–580 |doi=10.2165/11632850-000000000-00000 |pmid=22650381 |s2cid=22522914 }}

Asperger syndrome and autism tend to get undiagnosed or delayed recognition and delayed diagnosis{{cite journal |last1=Brett |first1=Denise |last2=Warnell |first2=Frances |last3=McConachie |first3=Helen |last4=Parr |first4=Jeremy R. |title=Factors Affecting Age at ASD Diagnosis in UK: No Evidence that Diagnosis Age has Decreased Between 2004 and 2014 |journal=Journal of Autism and Developmental Disorders |year=2016 |volume=46 |issue=6 |pages=1974–1984 |doi=10.1007/s10803-016-2716-6 |pmid=27032954 |pmc=4860193 }}{{cite journal |last1=Lehnhardt |first1=F.-G. |last2=Gawronski |first2=A. |last3=Volpert |first3=K. |last4=Schilbach |first4=L. |last5=Tepest |first5=R. |last6=Vogeley |first6=K. |title=Das psychosoziale Funktionsniveau spätdiagnostizierter Patienten mit Autismus-Spektrum-Störungen – eine retrospektive Untersuchung im Erwachsenenalter |trans-title=Psychosocial functioning of adults with late diagnosed autism spectrum disorders--a retrospective study |language=de |journal=Fortschritte der Neurologie · Psychiatrie |date=15 November 2011 |volume=80 |issue=2 |pages=88–97 |doi=10.1055/s-0031-1281642 |pmid=22086712 |s2cid=25077268 }} or misdiagnosed.{{cite journal |last1=Aggarwal |first1=Shilpa |last2=Angus |first2=Beth |title=Misdiagnosis versus missed diagnosis: diagnosing autism spectrum disorder in adolescents |journal=Australasian Psychiatry |date=4 February 2015 |volume=23 |issue=2 |pages=120–123 |doi=10.1177/1039856214568214 |pmid=25653302 |s2cid=43475267 }} Delayed or mistaken diagnosis can be traumatic for individuals and families; for example, misdiagnosis can lead to medications that worsen behavior.{{cite journal |last1=Corvin |first1=Aiden |last2=Fitzgerald |first2=Michael |title=Diagnosis and differential diagnosis of Asperger syndrome |journal=Advances in Psychiatric Treatment |year=2001 |volume=7 |issue=4 |pages=310–318 |doi=10.1192/apt.7.4.310 |doi-access=free }}{{cite journal |last1=Leskovec |first1=Thomas J. |last2=Rowles |first2=Brieana M. |last3=Findling |first3=Robert L. |title=Pharmacological Treatment Options for Autism Spectrum Disorders in Children and Adolescents |journal=Harvard Review of Psychiatry |date=March 2008 |volume=16 |issue=2 |pages=97–112 |doi=10.1080/10673220802075852 |pmid=18415882 |s2cid=26112061 }}

The DSM-5 field trials included "test-retest reliability" which involved different clinicians doing independent evaluations of the same patient—a new approach to the study of diagnostic reliability.{{cite web|url=http://www.dsm5.org/Documents/Reliability_and_Prevalence_in_DSM-5_Field_Trials_1-12-12.pdf |title=Reliability and Prevalence in the DSM-5 Field Trials |date=January 12, 2012 |access-date=2012-01-13 |archive-url=https://web.archive.org/web/20120131110008/http://www.dsm5.org/Documents/Reliability_and_Prevalence_in_DSM-5_Field_Trials_1-12-12.pdf |archive-date=2012-01-31}}

Misdiagnosis is the leading cause of medical error in outpatient facilities.

Since the National Institute of Medicine's 1999 [https://web.archive.org/web/20100726200809/http://iom.edu/~/media/Files/Report%20Files/1999/To-Err-is-Human/To%20Err%20is%20Human%201999%20%20report%20brief.pdf report], "To Err is Human," found up to 98,000 hospital patients die from preventable medical errors in the U.S. each year, government and private sector efforts have focused on inpatient safety.

{{Main|Medical prescription}}

While in 2000 the Committee on Quality of Health Care in America affirmed medical mistakes are an "unavoidable outcome of learning to practice medicine",{{cite book | author = Linda T. Kohn| author2 = Janet M. Corrigan | author3 = Molla S. Donaldson | pmid = 25077248 | title = To Err is Human: Building a Safer Health System | doi = 10.17226/9728 | year = 2000| isbn = 978-0-309-26174-6 }} at 2019 the commonly accepted link between prescribing skills and clinical clerkships was not yet demonstrated by the available data and in the U.S. legibility of handwritten prescriptions has been indirectly responsible for at least 7,000 deaths annually.{{Cite web|url=https://www.tdi.texas.gov/appeals/1999cases/991681r.pdf|title=APPEAL NO. 991681 Texas v. Dr. K|access-date=2020-04-16|archive-date=January 8, 2021|archive-url=https://web.archive.org/web/20210108050746/https://www.tdi.texas.gov/appeals/1999cases/991681r.pdf|url-status=live}}

Prescription errors concern ambiguous abbreviations, the right spelling of the full name of drugs: improper use of the nomenclature, of decimal points, unit or rate expressions; legibility and proper instructions; miscalculations of the posology (quantity, route and frequency of administration, duration of the treatment, dosage form and dosage strength); lack of information about patients (e.g. allergy, declining renal function) or reported in the medical document.{{cite journal | author = Raden Anita Indriyanti | author2 = Fajar Awalia Yulianto | author3 = Yuke Andriane | url = https://ejournal.unisba.ac.id/index.php/gmhc/article/view/4069 | title = Prescription Writing Errors in Clinical Clerkship among Medical Students | pages = 41–42 | doi = 10.29313/gmhc.v7i1.4069 | format = PDF | journal = Global Medical and Health Communication | year = 2019 | volume = 7 | via = DOAJ | issn = 2301-9123 | oclc = 8186593909 | archive-url = https://web.archive.org/web/20200926142205/https://ejournal.unisba.ac.id/index.php/gmhc/article/view/4069/pdf | archive-date = September 26, 2020 | url-status = live| doi-access = free }} There were an estimated 66 million clinically significant medication errors in the British NHS in 2018. The resulting adverse drug reactions are estimated to cause around 700 deaths a year in England and to contribute to around 22,000 deaths a year. The British researchers did not find any evidence that error rates were lower in other countries, and the global cost was estimated at $42 billion per year.{{cite news |last1=Elliott |first1=Rachel |title=PREVALENCE AND ECONOMIC BURDEN OF MEDICATION ERRORS IN THE NHS IN ENGLAND |url=https://www.bpsassessment.com/wp-content/uploads/2020/06/1.-Prevalence-and-economic-burden-of-medication-errors-in-the-NHS-in-England-1.pdf |access-date=19 June 2022 |agency=Policy Research Unit in Economic Evaluation of Health & Care Interventions |publisher=University of Sheffield |date=22 February 2018 |archive-date=September 26, 2022 |archive-url=https://web.archive.org/web/20220926082420/https://www.bpsassessment.com/wp-content/uploads/2020/06/1.-Prevalence-and-economic-burden-of-medication-errors-in-the-NHS-in-England-1.pdf |url-status=live }}

Medication errors in hospital include omissions, delayed dosing and incorrect medication administrations. Medication errors are not always readily identified, but can be reported using case note reviews or incident reporting systems.{{cite journal | last1=Mill | first1=Deanna | last2=Bakker | first2=Michael | last3=Corre | first3=Lauren | last4=Page | first4=Amy | last5=Johnson | first5=Jacinta | title=A comparison between Parkinson's medication errors identified through retrospective case note review versus via an incident reporting system during hospital admission | journal=International Journal of Pharmacy Practice | volume=28 | issue=6 | date=2020-11-06 | issn=0961-7671 | doi=10.1111/ijpp.12668 | pages=663–666| pmid=32844477 }} There are pharmacist-led interventions that can reduce the incident of medication error.{{cite journal | doi=10.1002/jppr.1699 | title=The impact of pharmacist-led strategies implemented to reduce errors related to cancer therapies: A systematic review | year=2020 | last1=Coutsouvelis | first1=John | last2=Siderov | first2=Jim | last3=Tey | first3=Amanda Y. | last4=Bortz | first4=Hadley D. | last5=o'Connor | first5=Shaun R. | last6=Rowan | first6=Gail D. | last7=Vasileff | first7=Hayley M. | last8=Page | first8=Amy T. | last9=Percival | first9=Mia A. | journal=Journal of Pharmacy Practice and Research | volume=50 | issue=6 | pages=466–480 | s2cid=229332634 | doi-access=free }} Electronic prescribing has been shown to reduce prescribing errors by up to 30%.{{cite journal |last1=Donyai |first1=Parastou |title=The effects of electronic prescribing on the quality of prescribing |journal=British Journal of Clinical Pharmacology |publisher=Br J Clin Pharmacol |date=February 2008|volume=65 |issue=2 |pages=230–237 |doi=10.1111/j.1365-2125.2007.02995.x |pmid=17662088 |pmc=2253693 }}

Mistakes can have a strongly negative emotional impact on the doctors who commit them.{{cite journal |vauthors=Hilfiker D |title=Facing our mistakes |journal=N. Engl. J. Med. |volume=310 |issue=2 |pages=118–22 |year=1984 |pmid=6690918 |doi=10.1056/NEJM198401123100211}}{{cite journal |vauthors=Christensen JF, Levinson W, Dunn PM |title=The heart of darkness: the impact of perceived mistakes on physicians |journal=Journal of General Internal Medicine |volume=7 |issue=4 |pages=424–31 |year=1992 |pmid=1506949 |doi=10.1007/bf02599161|s2cid=415258 }}{{cite journal |author=Wu AW |title=Medical error: the second victim : The doctor who makes the mistake needs help too |journal=BMJ |volume=320 |issue=7237 |pages=726–7 |year=2000 |pmid=10720336 |doi= 10.1136/bmj.320.7237.726|pmc=1117748}}{{cite journal |vauthors=Waterman AD, Garbutt J, Hazel E, Dunagan WC, Levinson W, Fraser VJ, Gallagher TH |title=The Emotional Impact of Medical Errors on Practicing Physicians in the United States and Canada |journal=Joint Commission Journal on Quality and Patient Safety |volume=33 |issue= 2|pages=467–476 |year=2007 |pmid=17724943 |doi=10.1016/S1553-7250(07)33050-X }}

Some physicians recognize that adverse outcomes from errors usually do not happen because of an isolated error and actually reflect system problems.{{cite journal |vauthors=Wu AW, Folkman S, McPhee SJ, Lo B |title=Do house officers learn from their mistakes? |journal=JAMA |volume=265 |issue=16 |pages=2089–94 |year=1991 |pmid=2013929 |doi=10.1001/jama.265.16.2089 }} This concept is often referred to as the Swiss Cheese Model.{{cite journal|vauthors=Dean B, Barber N, Schachter M |title=What is a prescribing error?|journal=Qual Saf Health Care|date=Oct 2000|volume=9|issue=4|pages=232–237 |doi=10.1136/qhc.9.4.232 |pmid=11101708 |pmc=1743540}} This is the concept that there are layers of protection for clinicians and patients to prevent mistakes from occurring. Therefore, even if a doctor or nurse makes a small error (e.g. incorrect dose of drug written on a drug chart by doctor), this is picked up before it actually affects patient care (e.g. pharmacist checks the drug chart and rectifies the error). Such mechanisms include:

Practical alterations (e.g.-medications that cannot be given through IV, are fitted with tubing which means they cannot be linked to an IV even if a clinician makes a mistake and tries to),{{cite journal|last1=Romero-Perez|first1=Raquel|first2=Philippa|last2=Hildick-Smith|title=Minimising Prescribing Errors in Paediatrics - Clinical Audit|journal=Scottish Universities Medical Journal|date=September 2012|volume=1|pages=14–1|url=http://sumj.dundee.ac.uk/data/uploads/epub-article/014-sumj.epub.pdf|access-date=June 22, 2016|archive-date=January 10, 2021|archive-url=https://web.archive.org/web/20210110100836/http://sumj.dundee.ac.uk/data/uploads/epub-article/014-sumj.epub.pdf|url-status=live}} systematic safety processes (e.g. all patients must have a Waterlow score assessment and falls assessment completed on admission), and training programmes/continuing professional development courses are measures that may be put in place.

There may be several breakdowns in processes to allow one adverse outcome.{{cite journal |last1=Gandhi |first1=Tejal K. |last2=Kachalia |first2=Allen |last3=Thomas |first3=Eric J. |last4=Puopolo |first4=Ann Louise |last5=Yoon |first5=Catherine |last6=Brennan |first6=Troyen A. |last7=Studdert |first7=David M. |title=Missed and Delayed Diagnoses in the Ambulatory Setting: A Study of Closed Malpractice Claims |journal=Annals of Internal Medicine |date=3 October 2006 |volume=145 |issue=7 |pages=488–96 |doi=10.7326/0003-4819-145-7-200610030-00006 |pmid=17015866 |s2cid=29006252 }} In addition, errors are more common when other demands compete for a physician's attention.{{cite journal |last1=Redelmeier |first1=Donald A. |last2=Tan |first2=Siew H. |last3=Booth |first3=Gillian L. |title=The Treatment of Unrelated Disorders in Patients with Chronic Medical Diseases |journal=New England Journal of Medicine |date=21 May 1998 |volume=338 |issue=21 |pages=1516–1520 |doi=10.1056/NEJM199805213382106 |pmid=9593791 |doi-access=free }}{{cite journal |last1=Lurie |first1=Nicole |last2=Rank |first2=Brian |last3=Parenti |first3=Connie |last4=Woolley |first4=Tony |last5=Snoke |first5=William |title=How Do House Officers Spend Their Nights? |journal=New England Journal of Medicine |date=22 June 1989 |volume=320 |issue=25 |pages=1673–1677 |doi=10.1056/NEJM198906223202507 |pmid=2725617 }}{{cite journal |vauthors=Lyle CB, Applegate WB, Citron DS, Williams OD |title=Practice habits in a group of eight internists |journal=Ann. Intern. Med. |volume=84 |issue=5 |pages=594–601 |year=1976 |pmid=1275366 |doi=10.7326/0003-4819-84-5-594}} However, placing too much blame on the system may not be constructive.

Essayists imply that the potential to make mistakes is part of what makes being a physician rewarding and without this potential the rewards of medical practice would be diminished. Laurence states that "Everybody dies, you and all of your patients. All relationships end. Would you want it any other way? [...] Don't take it personally".{{cite book |author1=Thomas Laurence |chapter=What Do You Want?|title=Extreme Clinic -- An Outpatient Doctor's Guide to the Perfect 7 Minute Visit |publisher=Hanley & Belfus |location=Philadelphia |year=2004 |isbn=978-1-56053-603-1 |page=120}}

Seder states "[...] if I left medicine, I would mourn its loss as I've mourned the passage of my poetry. On a daily basis, it is both a privilege and a joy to have the trust of patients and their families and the camaraderie of peers. There is no challenge to make your blood race like that of a difficult case, no mind game as rigorous as the challenging differential diagnosis, and though the stakes are high, so are the rewards."{{cite journal |author=Seder D |title=Of poems and patients |journal=Ann. Intern. Med. |volume=144 |issue=2 |pages=142 |year=2006 |pmid=16418416 |doi=10.7326/0003-4819-144-2-200601170-00014|s2cid=2927435 }}

Forgiveness, which is part of many cultural traditions, may be important in coping with medical mistakes.{{cite journal |last1=Berlinger |first1=N |last2=Wu |first2=AW |title=Subtracting insult from injury: addressing cultural expectations in the disclosure of medical error |journal=Journal of Medical Ethics |date=1 February 2005 |volume=31 |issue=2 |pages=106–108 |doi=10.1136/jme.2003.005538 |pmid=15681676 |pmc=1734098 }} Among other healing processes, it can be accomplished through the use of communicative disclosure guidelines.{{Cite web|title=Medical Error Disclosure Competence (MEDC) -- Prof. Dr. Annegret Hannawa|url=https://annegrethannawa.com/medc|access-date=2021-04-21|website=prof. annegret hannawa|language=en-US|archive-date=April 21, 2021|archive-url=https://web.archive.org/web/20210421143753/https://annegrethannawa.com/medc|url-status=live}}

Inability to forgive oneself may create a cycle of distress and increased likelihood of a future error.{{cite journal |last1=West |first1=Colin P. |last2=Huschka |first2=Mashele M. |last3=Novotny |first3=Paul J. |last4=Sloan |first4=Jeff A. |last5=Kolars |first5=Joseph C. |last6=Habermann |first6=Thomas M. |last7=Shanafelt |first7=Tait D. |title=Association of Perceived Medical Errors With Resident Distress and Empathy |journal=JAMA |date=6 September 2006 |volume=296 |issue=9 |pages=1071–8 |doi=10.1001/jama.296.9.1071 |pmid=16954486 |doi-access=free }}

However, Wu et al. suggest "...those who coped by accepting responsibility were more likely to make constructive changes in practice, but [also] to experience more emotional distress."{{cite journal |vauthors=Wu AW, Folkman S, McPhee SJ, Lo B |title=How house officers cope with their mistakes |journal=West. J. Med. |volume=159 |issue=5 |pages=565–9 |year=1993 |pmid=8279153 |pmc=1022346}} It may be helpful to consider the much larger number of patients who are not exposed to mistakes and are helped by medical care.

Gallagher et al. state that patients want "information about what happened, why the error happened, how the error's consequences will be mitigated, and how recurrences will be prevented."{{cite journal |vauthors=Gallagher TH, Waterman AD, Ebers AG, Fraser VJ, Levinson W |title=Patients' and physicians' attitudes regarding the disclosure of medical errors |journal=JAMA |volume=289 |issue=8 |pages=1001–7 |year=2003 |pmid=12597752 |doi=10.1001/jama.289.8.1001|doi-access=free }} Interviews with patients and families reported in a 2003 book by Rosemary Gibson and Janardan Prasad Singh, put forward that those who have been harmed by medical errors face a "wall of silence" and "want an acknowledgement" of the harm.{{cite book |author1=Rosemary Gibson |author2=Janardan Prasad Singh |title=Wall of Silence |year=2003 |publisher=Regnery |isbn=978-0-89526-112-0 |url=https://archive.org/details/wallofsilenceunt00gibs }} With honesty, "healing can begin not just for the patients and their families but also the doctors, nurses and others involved." In a line of experimental investigations, Annegret Hannawa et al. developed evidence-based disclosure guidelines under the scientific "Medical Error Disclosure Competence (MEDC)" framework.{{cite journal |last1=Wu |first1=Albert W. |last2=Cavanaugh |first2=Thomas A. |last3=McPhee |first3=Stephen J. |last4=Lo |first4=Bernard |last5=Micco |first5=Guy P. |title=To tell the truth |journal=Journal of General Internal Medicine |date=December 1997 |volume=12 |issue=12 |pages=770–775 |doi=10.1046/j.1525-1497.1997.07163.x |pmid=9436897 |pmc=1497204 }}

A review of studies examining patients' views on investigations of medical harm found commonalities in their expectations of the process. For example, many wanted reviews to be transparent, trustworthy, and person-centred to meet their needs. People wanted to be meaningfully involved in the process and to be treated with respect and empathy. Justice-seekers wanted an honest account of what happened, the circumstances leading up to it, and measures to ensure it does not happen again. Processes that, for example, involved people independent of the organisation responsible for harm gave investigations credibility.{{Cite journal |last1=Shaw |first1=Liz |last2=Lawal |first2=Hassanat M. |last3=Briscoe |first3=Simon |last4=Garside |first4=Ruth |last5=Thompson Coon |first5=Jo |last6=Rogers |first6=Morwenna |last7=Melendez-Torres |first7=G. J. |date=2023-12-01 |title=Patient, carer and family experiences of seeking redress and reconciliation following a life-changing event: Systematic review of qualitative evidence |journal=Health Expectations |language=en |volume=26 |issue=6 |pages=2127–2150 |doi=10.1111/hex.13820 |issn=1369-6513 |pmc=10632635 |pmid=37452516}}{{Cite journal |date=10 January 2024 |title=How to improve investigations of medical harm |url=https://evidence.nihr.ac.uk/alert/how-to-improve-investigations-of-medical-harm/ |journal=NIHR Evidence |doi=10.3310/nihrevidence_61101 |s2cid=266946352 |access-date=January 12, 2024 |archive-date=January 12, 2024 |archive-url=https://web.archive.org/web/20240112160213/https://evidence.nihr.ac.uk/alert/how-to-improve-investigations-of-medical-harm/ |url-status=live }}

A 2005 study by Wendy Levinson of the University of Toronto showed surgeons discussing medical errors used the word "error" or "mistake" in only 57 percent of disclosure conversations and offered a verbal apology only 47 percent of the time.{{cite web | last=Kelly | first=Karen | year=2005 | url=http://www.news.utoronto.ca/bin6/051117-1824.asp | title=Study explores how physicians communicate mistakes | publisher=University of Toronto | access-date=2006-03-17 |archive-url = https://web.archive.org/web/20060322154328/http://www.news.utoronto.ca/bin6/051117-1824.asp |archive-date = 2006-03-22}}

Patient disclosure is important in the medical error process. The current standard of practice at many hospitals is to disclose errors to patients when they occur. In the past, it was a common fear that disclosure to the patient would incite a malpractice lawsuit. Many physicians would not explain that an error had taken place, causing a lack of trust toward the healthcare community. In 2007, 34 states passed legislation that precludes any information from a physician's apology for a medical error from being used in malpractice court (even a full admission of fault).{{Cite web |url=http://psnet.ahrq.gov/primer.aspx?primerID=2 |title=Archived copy |access-date=April 25, 2009 |archive-date=September 6, 2015 |archive-url=https://web.archive.org/web/20150906053931/http://psnet.ahrq.gov/primer.aspx?primerID=2 |url-status=live }} This encourages physicians to acknowledge and explain mistakes to patients, keeping an open line of communication.

The American Medical Association's Council on Ethical and Judicial Affairs states in its ethics code:

:"Situations occasionally occur in which a patient suffers significant medical complications that may have resulted from the physician's mistake or judgment. In these situations, the physician is ethically required to inform the patient of all facts necessary to ensure understanding of what has occurred. Concern regarding legal liability which might result following truthful disclosure should not affect the physician's honesty with a patient."

From the American College of Physicians Ethics Manual:{{cite journal |vauthors=Snyder L, Leffler C |title=Ethics manual: fifth edition |journal=Ann Intern Med |volume=142 |issue=7 |pages=560–82 |year=2005 |pmid=15809467 |last3=Ethics Human Rights Committee |doi=10.7326/0003-4819-142-7-200504050-00014|s2cid=53090205 }}

:"In addition, physicians should disclose to patients information about procedural or judgment errors made in the course of care if such information is material to the patient's well-being. Errors do not necessarily constitute improper, negligent, or unethical behavior, but failure to disclose them may."

However, "there appears to be a gap between physicians' attitudes and practices regarding error disclosure. Willingness to disclose errors was associated with higher training level and a variety of patient-centered attitudes, and it was not lessened by previous exposure to malpractice litigation".{{cite journal |vauthors=Kaldjian LC, Jones EW, Wu BJ, Forman-Hoffman VL, Levi BH, Rosenthal GE |title=Disclosing Medical Errors to Patients: Attitudes and Practices of Physicians and Trainees |journal=Journal of General Internal Medicine |volume=22 |issue=7 |pages=988–96 |year=2007 |pmid=17473944 |doi=10.1007/s11606-007-0227-z |pmc=2219725}} Hospital administrators may share these concerns.{{cite journal |vauthors=Weissman JS, Annas CL, Epstein AM, etal |title=Error reporting and disclosure systems: views from hospital leaders |journal=JAMA |volume=293 |issue=11 |pages=1359–66 |year=2005 |pmid=15769969 |doi=10.1001/jama.293.11.1359|doi-access=free }}

Consequently, in the United States, many states have enacted laws excluding expressions of sympathy after accidents as proof of liability.

Disclosure may actually reduce malpractice payments.{{cite journal |vauthors=Wu AW |title=Handling hospital errors: is disclosure the best defense? |journal=Ann. Intern. Med. |volume=131 |issue=12 |pages=970–2 |year=1999 |pmid=10610651 |doi=10.7326/0003-4819-131-12-199912210-00012|s2cid=36889006 }}{{cite news |author=Zimmerman R |title=Doctors' New Tool To Fight Lawsuits: Saying 'I'm Sorry' |url=https://www.wsj.com/articles/SB108482777884713711 |work= The Wall Street Journal |page=A1 |date=May 18, 2004|archive-url=https://web.archive.org/web/20070823101409/http://www.mc.vanderbilt.edu/root/vumc.php?site=CPPA&doc=3270|archive-date=August 23, 2007}}

Reluctance to disclose medical errors to patients may also stem from psychological reasons. In his book, Medical Errors and Medical Narcissism, John Banja defines "medical narcissism" as the need of health professionals to preserve their self-esteem leading to the compromise of error disclosure to patients.Banja, John, Medical Errors and Medical Narcissism, 2005

In a study of physicians who reported having made a mistake, it was offered that disclosing to non-physician sources of support may reduce stress more than disclosing to physician colleagues.{{cite journal |author=Newman MC |title=The emotional impact of mistakes on family physicians |journal=Archives of Family Medicine |volume=5 |issue=2 |pages=71–5 |year=1996 |pmid=8601210 |doi=10.1001/archfami.5.2.71}} This may be due to the finding that of the physicians in the same study, when presented with a hypothetical scenario of a mistake made by another colleague, only 32% of them would have unconditionally offered support. It is possible that greater benefit occurs when spouses are physicians.{{cite journal |last1=Sobecks |first1=Nancy W. |last2=Justice |first2=AC |last3=Hinze |first3=S |last4=Chirayath |first4=HT |last5=Lasek |first5=RJ |last6=Chren |first6=MM |last7=Aucott |first7=J |last8=Juknialis |first8=B |last9=Fortinsky |first9=R |last10=Youngner |first10=S |last11=Landefeld |first11=CS |title=When Doctors Marry Doctors: A Survey Exploring the Professional and Family Lives of Young Physicians |journal=Annals of Internal Medicine |date=16 February 1999 |volume=130 |issue=4_Part_1 |pages=312–9 |doi=10.7326/0003-4819-130-4-199902160-00017 |pmid=10068390 }}

Discussing mistakes with other physicians is beneficial. However, medical providers may be less forgiving of one another. The reason is not clear, but one essayist has admonished, "Don't Take Too Much Joy in the Mistakes of Other Doctors."{{cite book |author=Oscar London |chapter=Rule 35: Don't Take Too Much Joy in the Mistakes of Other Doctors |title=Kill as few patients as possible: and fifty-six other essays on how to be the world's best doctor |publisher=Ten Speed Press |location=Berkeley, Calif |year=1987 |isbn=978-0-89815-197-8 |chapter-url=https://archive.org/details/killasfewpatient00lond |url-access=registration |url=https://archive.org/details/killasfewpatient00lond }}

Disclosure of errors, especially "near misses", may be able to reduce subsequent errors in institutions that are capable of reviewing near misses.{{cite journal |last1=Barach |first1=P. |last2=Small |first2=SD |title=Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems |journal=BMJ |date=18 March 2000 |volume=320 |issue=7237 |pages=759–763 |doi=10.1136/bmj.320.7237.759 |pmid=10720361 |pmc=1117768 }} However, doctors report that institutions may not be supportive of the doctor.

Based on anecdotal and survey evidence, Banja{{cite book |last=Banja |first=John D. |title=Medical errors and medical narcissism |url=https://archive.org/details/medicalerrorsmed0000banj |url-access=registration |date=2005|location=Sudbury, Massachusetts |publisher=Jones and Bartlett |isbn=978-0-7637-8361-7 }} states that rationalization (making excuses) is very common among the medical profession to cover up medical errors.

In a survey of more than 10,000 physicians in the United States, when asked the question, "Are there times when it's acceptable to cover up or avoid revealing a mistake if that mistake would not cause harm to the patient?", 19% answered yes, 60% answered no and 21% answered it depends. On the question, "Are there times when it is acceptable to cover up or avoid revealing a mistake if that mistake would potentially or likely harm the patient?", 2% answered yes, 95% answered no and 3% answered it depends.{{cite web |first1=Gail Garfinkel |last1=Weiss |date=January 4, 2011 |title='Some Worms Are Best Left in the Can' -- Should You Hide Medical Errors? |url=https://www.medscape.com/viewarticle/735033 |website=Medscape |access-date=September 8, 2019 |archive-date=March 1, 2021 |archive-url=https://web.archive.org/web/20210301034307/https://www.medscape.com/viewarticle/735033 |url-status=live }}

{{Main|Medical malpractice}}

Standards and regulations for medical malpractice vary by country and jurisdiction within countries. Medical professionals may obtain professional liability insurances to offset the risk and costs of lawsuits based on medical malpractice.

{{Further|Patient safety}}

Medical care is frequently compared adversely to aviation; while many of the factors that lead to errors in both fields are similar, aviation's error management protocols are regarded as much more effective.{{cite journal |last1=Helmreich |first1=R. L |title=On error management: lessons from aviation |journal=BMJ |date=18 March 2000 |volume=320 |issue=7237 |pages=781–785 |doi=10.1136/bmj.320.7237.781 |pmid=10720367 |pmc=1117774 }} Safety measures include informed consent, the availability of a second practitioner's opinion, voluntary reporting of errors, root cause analysis, reminders to improve patient medication adherence, hospital accreditation, and systems to ensure review by experienced or specialist practitioners.{{cite journal |last1=Espinosa |first1=J. A |last2=Nolan |first2=TW |title=Reducing errors made by emergency physicians in interpreting radiographs: longitudinal study |journal=BMJ |date=18 March 2000 |volume=320 |issue=7237 |pages=737–740 |doi=10.1136/bmj.320.7237.737 |pmid=10720354 |pmc=27314 }}

A template has been developed for the design (both structure and operation) of hospital medication safety programmes, particularly for acute tertiary settings,{{cite journal |last1=Relihan |first1=Eileen C |last2=Silke |first2=Bernard |last3=Ryder |first3=Sheila A |title=Design template for a medication safety programme in an acute teaching hospital |journal=European Journal of Hospital Pharmacy |date=23 June 2012 |volume=19 |issue=3 |pages=340–344 |doi=10.1136/ejhpharm-2012-000050 |hdl=2262/66780 |s2cid=54178056 |hdl-access=free }} which emphasizes safety culture, infrastructure, data (error detection and analysis), communication and training.

Particularly to prevent the medication errors in the perspective of the intrathecal administration of local anaesthetics, there is a proposal to change the presentation and packaging of the appliances and agents used for this purpose. One spinal needle with a syringe prefilled with the local anaesthetic agents may be marketed in a single blister pack, which will be peeled open and presented before the anaesthesiologist conducting the procedure.{{cite journal | last=Alam | first=Rabiul | year=2016 | title=Spinal needle with prefilled syringe to prevent medication error: A proposal | journal=Indian Journal of Anaesthesia | volume=60 | issue=7 | pages=525–7 | doi=10.4103/0019-5049.186014 | pmid=27512177 | pmc=4966365 | doi-access=free }}

Physician well-being has also been recommended as an indicator of healthcare quality given its association with patient safety outcomes.{{cite journal |last1=West |first1=Colin P |year=2016 |title=Physician Well-Being: Expanding the Triple Aim |journal=Journal of General Internal Medicine |volume=31 |issue=5 |pages=458–459 |doi=10.1007/s11606-016-3641-2 |pmid=26921157 |pmc=4835383 }} A meta-analysis involving 21517 participants found that physicians with depressive symptoms had a 95% higher risk of reporting medical errors and that the association between physician depressive symptoms and medical errors is bidirectional

In the United States, adverse medical event reporting systems were mandated in just over half (27) of the states as of 2014, a figure unchanged since 2007.{{cite web|last1=Hanlon|first1=Carrie|last2=Sheedy|first2=Kaitlin|last3=Kniffin|first3=Taylor|last4=Rosenthal|first4=Jill|title=2014 Guide to State Adverse Event Reporting Systems|url=http://www.nashp.org/sites/default/files/2014_Guide_to_State_Adverse_Event_Reporting_Systems.pdf|website=NASHP.org|publisher=National Academy for State Health Policy|access-date=22 April 2016|year=2015|archive-date=February 2, 2017|archive-url=https://web.archive.org/web/20170202000851/http://www.nashp.org/sites/default/files/2014_Guide_to_State_Adverse_Event_Reporting_Systems.pdf|url-status=dead}}{{cite journal|title=A national survey of medical error reporting laws.|journal=Yale Journal of Health Policy, Law, and Ethics|year=2009|volume=9|issue=1|pages=201–86|pmid=19388488|url=http://www.yale.edu/yjhple/issues/vix-i1-win09/docs/feature.pdf|access-date=22 April 2016|archive-date=December 18, 2015|archive-url=https://web.archive.org/web/20151218195256/http://www.yale.edu/yjhple/issues/vix-i1-win09/docs/feature.pdf|url-status=dead}} In U.S. hospitals error reporting is a condition of payment by Medicare.{{Cite web |url=https://www.nytimes.com/2012/01/06/health/study-of-medicare-patients-finds-most-hospital-errors-unreported.html |title=Report Finds Most Errors at Hospitals Go Unreported |website=The New York Times |access-date=February 27, 2017 |archive-date=February 26, 2021 |archive-url=https://web.archive.org/web/20210226190043/https://www.nytimes.com/2012/01/06/health/study-of-medicare-patients-finds-most-hospital-errors-unreported.html |url-status=live }} An investigation by the Office of Inspector General, Department of Health and Human Services released January 6, 2012 found that most errors are not reported and even in the case of errors that are reported and investigated changes are seldom made which would prevent them in the future. The investigation revealed that there was often lack of knowledge regarding which events were reportable and recommended that lists of reportable events be developed.{{Cite web |url=http://oig.hhs.gov/oei/reports/oei-06-09-00091.asp |title=Summary Hospital Incident Reporting Systems Do Not Capture Most Patient Harm |access-date=January 6, 2012 |archive-date=January 14, 2016 |archive-url=https://web.archive.org/web/20160114053151/http://oig.hhs.gov/oei/reports/oei-06-09-00091.asp |url-status=dead }}

Traditionally, errors are attributed to mistakes made by individuals, who then may be penalized. A common approach to respond to and prevent specific errors is requiring additional checks at particular points in the system, whose findings and detail of execution must be recorded. As an example, an error of free flow IV administration of heparin is approached by teaching staff how to use the IV systems and to use special care in setting the IV pump. While overall errors become less likely, the checks add to workload and may in themselves be a cause of additional errors. In some hospitals, a regular morbidity and mortality conference meeting is scheduled to discuss complications or deaths and learn from or improve the overall processes.

A newer model for improvement in medical care takes its origin from the work of W. Edwards Deming in a model of Total Quality Management.{{Citation needed|date=July 2023}} In this model, there is an attempt to identify the underlying system defect that allowed the error to occur. As an example, in such a system the error of free flow IV administration of heparin is dealt with by not using IV heparin and substituting subcutaneous administration of heparin, obviating the entire problem. However, such an approach presupposes available research showing that subcutaneous heparin is as effective as IV. Thus, most systems use a combination of approaches to the problem.{{Citation needed|date=July 2023}}

The field of medicine that has taken the lead in systems approaches to safety is anaesthesiology.{{cite journal |last1=Gaba |first1=David M. |date=18 March 2000 |title=Anaesthesiology as a model for patient safety in health care |journal=BMJ |volume=320 |issue=7237 |pages=785–788 |doi=10.1136/bmj.320.7237.785 |pmc=1117775 |pmid=10720368}} Steps such as standardization of IV medications to 1 ml doses, national and international color-coding standards, and development of improved airway support devices has the field a model of systems improvement in care.

Reducing errors in prescribing, dispensing, compounding/formulating, labelling, and handling medications is a priority and has been the subject of systematic reviews and studies. Examples of areas to reduce medication errors and improve safety include: Training professionals or using databases to compare new and previous prescribed medications to prevent mistakes, also known as "medication reconciliation",{{Citation |last=Barnsteiner |first=Jane H. |title=Medication Reconciliation |year=2008 |url=http://www.ncbi.nlm.nih.gov/books/NBK2648/ |work=Patient Safety and Quality: An Evidence-Based Handbook for Nurses |editor-last=Hughes |editor-first=Ronda G. |access-date=2023-07-17 |series=Advances in Patient Safety |place=Rockville (MD) |publisher=Agency for Healthcare Research and Quality (US) |pmid=21328749 |archive-date=March 31, 2023 |archive-url=https://web.archive.org/web/20230331081303/https://ncbi.nlm.nih.gov/books/NBK2648/ |url-status=live }} prescribing through an electronic medical record system and/or using decision support systems that has automatic checks in place, with computerized alerts or other novel technologies, the use of machine-readable barcodes, healthcare professional and patient training or supplementary educational programs, adding in an extra step for double checking prescriptions (both at the level of the healthcare professional and at the administrator level), using standardized protocols in the workplace that include a check-list, physical markings or writing on syringes to indicate correct doses, programmes that include the person being able to administer the medications themselves, ensuring that the workplace or environment is well-lit, monitoring and adjusting healthcare professional working hours, and the use of an interdisciplinary team. There is weak evidence indicating that a number of these suggested interventions may be helpful in reducing errors or improving patient safety, however, in general, evidence supporting the best or most effective intervention for reducing errors not strong.{{Cite journal |last1=Khalil |first1=Hanan |last2=Bell |first2=Brian |last3=Chambers |first3=Helen |last4=Sheikh |first4=Aziz |last5=Avery |first5=Anthony J |date=2017-10-04 |editor-last=Cochrane Effective Practice and Organisation of Care Group |title=Professional, structural and organisational interventions in primary care for reducing medication errors |journal=Cochrane Database of Systematic Reviews |language=en |volume=2017 |issue=10 |pages=CD003942 |doi=10.1002/14651858.CD003942.pub3 |pmc=6485628 |pmid=28977687}} Evidence supporting improvements aimed at reducing medical errors in medications for pediatric hospitalized patients is also very weak.{{Cite journal |last1=Maaskant |first1=Jolanda M |last2=Vermeulen |first2=Hester |last3=Apampa |first3=Bugewa |last4=Fernando |first4=Bernard |last5=Ghaleb |first5=Maisoon A |last6=Neubert |first6=Antje |last7=Thayyil |first7=Sudhin |last8=Soe |first8=Aung |date=2015-03-10 |editor-last=Cochrane Effective Practice and Organisation of Care Group |title=Interventions for reducing medication errors in children in hospital |journal=Cochrane Database of Systematic Reviews |issue=3 |pages=CD006208 |language=en |doi=10.1002/14651858.CD006208.pub3|pmid=25756542 |pmc=10799669 }}

As far back as the 1930s, pharmacists worked with physicians to select, from many options, the safest and most effective drugs available for use in hospitals.{{cite journal |author=Pease E |year=1936 |title=Minimum standards for a hospital pharmacy |journal=Bull Am Coll Surg |volume=21 |pages=34–35}} The process is known as the Formulary System and the list of drugs is known as the Formulary. In the 1960s, hospitals implemented unit dose packaging and unit dose drug distribution systems to reduce the risk of wrong drug and wrong dose errors in hospitalized patients;{{cite book |author=Garrison TJ |url=https://archive.org/details/handbookofinstit00smit |title=IV.1 Medication Distribution Systems |date=1979 |publisher=Williams and Wilkins |isbn=978-0-683-07884-8 |editor1=Smith MC |editor2=Brown TR}} centralized sterile admixture services were shown to decrease the risks of contaminated and infected intravenous medications;{{cite book |author1=Woodward WA |url=https://archive.org/details/handbookofinstit00smit |title=Chapter IV.3 Developing Intravenous Admixture Systems |author2=Schwartau N |date=1979 |publisher=Williams and Wilkins |isbn=978-0-683-07884-8 |editor1=Smith MC |editor2=Brown TR}}{{cite book |author1=Powell MF |title=Chapter 53 The Patient Profile System |date=1986 |publisher=Williams and Wilkins |isbn=978-0-683-01090-9 |editor1=Smith MC |edition=2 |editor2=Brown TR}} and pharmacists provided drug information and clinical decision support directly to physicians to improve the safe and effective use of medications.{{cite book |author1=Evens RP |title=Chapter 31 Communicating Drug Information |date=1986 |publisher=Williams and Wilkins |isbn=978-0-683-01090-9 |editor1=Smith MC |edition=2 |editor2=Brown TR}} Pharmacists are recognized experts in medication safety and have made many contributions that reduce error and improve patient care over the last 50 years. More recently, governments have attempted to address issues like patient-pharmacist communication and consumer knowledge through measures like the Australian Government's Quality Use of Medicines policy.{{Citation needed|date=July 2023}}

Some common misconceptions about medical error include:

• Medical error is the "third leading cause of death" in the United States. This canard stems from an erroneous 2016 study which, according to David Gorski, "has taken on a life of its own" and fuelled "a myth promulgated by both quacks and academics".{{cite web |vauthors=Gorski DH |publisher=Science-Based Medicine |date=4 February 2019 |title=Are medical errors really the third most common cause of death in the U.S.? (2019 edition) |url=https://sciencebasedmedicine.org/are-medical-errors-really-the-third-most-common-cause-of-death-in-the-u-s-2019-edition/ |access-date=June 6, 2022 |archive-date=June 7, 2022 |archive-url=https://web.archive.org/web/20220607212556/https://sciencebasedmedicine.org/are-medical-errors-really-the-third-most-common-cause-of-death-in-the-u-s-2019-edition/ |url-status=live }}
• "Bad apples" or incompetent health care providers are a common cause. (Although human error is commonly an initiating event, the faulty care delivery process invariably permits or compounds the harm and so is the focus of improvement.)
• High-risk procedures or medical specialties are responsible for most avoidable adverse events. (Although some mistakes, such as in surgery, are harder to conceal, errors occur in all levels of care. Even though complex procedures entail more risk, adverse outcomes are not usually due to error, but to the severity of the condition being treated.){{cite journal |author1=René Amalberti |author2=Yves Auroy |author3=Don Berwick |author4=Paul Barach | date=3 May 2005| title = Five System Barriers to Achieving Ultrasafe Health Care | journal = Annals of Internal Medicine | volume = 142 | pages = 756–764 | pmid = 15867408 | issue = 9 | doi=10.7326/0003-4819-142-9-200505030-00012| doi-access=free }} However, United States Pharmacopeia has reported that medication errors during the course of a surgical procedure are three times more likely to cause harm to a patient than those occurring in other types of hospital care.
• If a patient experiences an adverse event during the process of care, an error has occurred. (Most medical care entails some level of risk, and there can be complications or side effects, even unforeseen ones, from the underlying condition or from the treatment itself.){{cite book |last=Institute of Medicine |year=2000 |url=http://www.nap.edu/catalog/9728 |title=To Err Is Human: Building a Safer Health System |location=Washington, DC |publisher=The National Academies Press |isbn=978-0-309-26174-6 |doi=10.17226/9728 |doi-access=free |pmid=25077248 |page=4 |access-date=June 22, 2016 |archive-date=June 16, 2020 |archive-url=https://web.archive.org/web/20200616054548/https://www.nap.edu/catalog/9728/to-err-is-human-building-a-safer-health-system |url-status=live }}

{{col div|colwidth=25em}}

• Serious adverse event
• Adverse drug reaction
• Biosafety
• Emily's Law
• Fatal Care: Survive in the U.S. Health System (book)
• Medical malpractice
• Medical resident work hours
• Sleep deprivation
• Patient Safety and Quality Improvement Act of 2005
• Patient safety organization
• Quality use of medicines

{{colend}}

{{Reflist}}

• {{Cite book |author-link=Atul Gawande |last=Gawande |first=Atul |title=Complications: A Surgeon's Notes on an Imperfect Science |location=New York |publisher=Metropolitan Books |year=2002 |isbn=978-0-8050-6319-6 |url-access=registration |url=https://archive.org/details/complicationssu000gawa }}
• {{Cite book |last1=Wachter |first1=Robert |last2=Shojania |first2=Kaveh |title=Internal Bleeding: The Truth Behind America's Terrifying Epidemic of Medical Mistakes |url=https://archive.org/details/internalbleeding0000wach |url-access=registration |location=New York |publisher=Rugged Land |year=2004 |isbn=978-1-59071-016-6 }}
• {{Cite book |last=Banja |first=John |title=Medical Errors and Medical Narcissism |year=2005 |location=Boston |publisher=Jones and Bartlett |isbn=978-0-7637-8361-7 |title-link=Narcissism#Medical narcissism }}
• {{Cite book |last1=Porter |first1=Michael E. |last2=Olmsted Teisberg |first2=Elizabeth |title=Redefining Health Care: Creating Value-Based Competition on Results |year=2006 |location=Boston |publisher=Harvard Business School Press |isbn=978-1-59139-778-6 |url=https://archive.org/details/redefininghealth00port }}
• {{Cite book |last1=Gibson |first1=Rosemary |last2=Prasad Singh |first2=Janardan |title=Wall of Silence: The Untold Story of the Medical Mistakes That Kill and Injure Millions of Americans |year=2003 |location=Washington D.C. |publisher=Regnery |isbn=978-0-89526-112-0 |url=https://archive.org/details/wallofsilenceunt00gibs }}
• {{cite journal | doi = 10.1211/ijpp.16.5.0007 |author=Alldred D.P. |author2=Standage C. |author3=Zermansky A.G. |author4=Jesson B. |author5=Savage I. |author6=Franklin B.D. |author7=Barber N. |author8=Raynor D.K. | year = 2008 | title = Development and validation of criteria to identify medication-monitoring errors in care home residents | journal = International Journal of Pharmacy Practice | volume = 16 | issue = 5| pages = 317–323|s2cid=71701489 |doi-access=free }}
• {{cite book | title=Preventing medication errors |publisher=National Academies Press |last1=Committee on Identifying and Preventing Medication Errors |last2=Board on Health Care Services |url=http://www.nap.edu/read/11623/ |isbn=978-0-309-10147-9 |date=2007 }}
• {{cite journal |title= VEINROM: A possible solution for erroneous intravenous drug administration|journal= Journal of Anaesthesiology Clinical Pharmacology|volume=30 |issue=2 |pages=263–266 |doi=10.4103/0970-9185.130055|pmid=24803770 |pmc=4009652 |year=2014 |last1=Tewari |first1=A. |last2=Palm |first2=B. |last3=Hines |first3=T. |last4=Royer |first4=T. |last5=Alexander |first5=E. |doi-access= free}}

{{Medical harm}}

{{Authority control}}

Category:Medical diagnosis

Category:Patient safety