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{\huge \textbf{Medical Errors: Types, Causes, and Prevention Strategies}}\\
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{\Large A Comprehensive Analysis}\\
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{\large José Daniel Sánchez Redrobán$^{1}$, Hanny Corvalán Reinthaller$^{2}$}\\
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{\normalsize
$^{1}$Universidad Tecnológica Indoamérica, Faculty of Health Sciences and Human Welfare, 170301, Quito -- Ecuador\\
\texttt{danielsanchez@uti.edu.ec}, ORCID: 0000-0003-4571-1618\\
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$^{2}$Independent researcher, Durham -- North Carolina\\
ORCID: 0009-0009-2003-1035\\
}
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{\large \today}
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\begin{abstract}
Medical errors are acts or omissions committed by healthcare professionals that can lead to adverse events, which are defined as injuries or conditions caused by medical treatments rather than the disease itself. They have been one of the leading causes of death in the United States and constitute a serious and complex problem affecting healthcare systems globally. This paper explores medical errors, their types, causes, and consequences, as well as strategies to prevent them. These strategies include improved patient-provider communication, continuous training, and the implementation of new technology tools and reporting systems. The paper focuses on a multidisciplinary approach to create a safe environment where healthcare providers feel comfortable reporting errors without fear of retribution. It highlights the need to foster a patient safety-based culture and emphasizes the importance of ethics committees when navigating medical errors. This document also delves into diagnostic error, its causes and consequences, as well as prevention strategies. Ethical considerations, legal liability, and the crucial role of communication, training, and technology in improving patient safety are discussed, underscoring the fundamental role of ethics committees in the management of medical errors.
\end{abstract}

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\section{Introduction}
Despite advances in medicine and the noble purpose of preserving life and helping those in need, healthcare is not infallible, and healthcare professionals are not exempt from making mistakes despite good intentions. Human error is always a factor that must be considered, especially given the challenges of the healthcare environment such as sleep deprivation, high patient load, and a fast-paced workflow. When these factors coincide, mistakes are inevitable, but this does not mean that prevention strategies cannot be implemented to reduce their frequency and severity, as well as their impact on the healthcare system, including patients, providers, facilities, and national healthcare institutions.

\section{Definition and Scope of the Problem}
A medical error can be defined as \textit{any act or omission committed by a healthcare professional during patient care that causes or has the potential to cause harm to the patient rather than the disease itself}. These errors can occur at any stage of the care process, from admission and diagnosis to treatment and follow-up. According to recent studies, the extent of this problem is extraordinarily concerning, given that medical errors remain a leading cause of death, disability, and illness worldwide. The World Health Organization estimates that each year millions of patients suffer the consequences of preventable medical errors, resulting in considerable economic costs to healthcare systems and a substantial burden on patients and their families.

Medical errors can occur at any point in the patient care process. The most common types include:

\begin{enumerate}
  \item \textbf{Diagnostic errors:} These include incorrect, delayed, or missed diagnoses, as well as overdiagnosis, which can lead to unnecessary and potentially harmful treatments.

  \item \textbf{Treatment errors:} These cover errors in prescribing, administering, and monitoring medications, as well as errors in surgical procedures and other medical treatments.

  \item \textbf{Prevention errors:} These refer to the failure to implement preventive measures, such as vaccination or disease screening, which can increase the risk of complications and diseases.

  \item \textbf{Communication errors:} These include failures in communication between healthcare professionals and patients, as well as communication with other professionals, which can lead to misunderstandings and incorrect clinical decisions.
\end{enumerate}

It is important to recognize that medical errors are not always the result of negligence or incompetence of healthcare professionals; they are often the result of a complex interaction of many factors, including healthcare system limitations, lack of resources, personnel fatigue, care pressure, and cognitive biases.

\section{Impact of Medical Errors on Public Health and the Economy}
Medical errors have a significant impact on public health matters. Not only are they one of the leading causes of death among patients of all ages in the United States, but they can also lead to long-term disease and disability. This translates into increased length of hospital stays and additional treatments, which further increases the risk for many other conditions, making it a complex situation to resolve.

From an economic standpoint, medical errors can have a profound impact on the perceived efficacy of the healthcare system, reducing patient trust and therefore decreasing the likelihood of seeking medical help when needed. They can also cause irreparable damage to the reputation of healthcare professionals and facilities, who must face the costs associated with additional treatments and legal compensations, as well as indirect costs such as decreased productivity and personnel burnout.

Direct costs include expenses associated with the treatment of complications and adverse events, as well as compensation for medical negligence. Indirect costs, such as lost productivity and social costs, are also relevant. Medical errors represent a complex and multifactorial problem that affects patients, healthcare professionals, and healthcare systems worldwide. Their impact on public health and the economy is considerable, revealing the urgent need to address this problem effectively.

\section{Historical Perspective of Patient Safety}
Although medical errors have existed since the beginning of medical practice, it was only in the 20th century that they were addressed as a healthcare problem that could be prevented. In 1999, the United States Institute of Medicine published a report called \textit{"To Err is Human: Building a Safer Health System,"} which opened the discussion about medical errors, highlighted the magnitude of the problem, and called for action from the healthcare system to improve patient safety conditions.

Since that publication, many other authors have addressed the issue, and numerous initiatives have been tested and implemented to reduce medical errors, including the development of reporting systems, continuous training, and the implementation of new technologies to improve safety in healthcare. However, despite all these efforts, medical errors continue to occur. The healthcare system is extraordinarily complex, and while advances help preserve patients' health, they also add more layers of complexity for providers, who must continuously study to remain updated while managing high patient loads, fast-paced environments, and chronic exhaustion.

Health system complexity, human variability, and resource limitations continue to pose significant challenges to patient safety. It is essential to continue investigating the causes of medical errors and develop effective strategies to prevent them and mitigate their consequences.

\section{Classification of Medical Errors According to Their Seriousness and Consequences}
A medical error is the act or omission made by a healthcare provider that can lead to negative consequences for the patient. When a medical error occurs, it is crucial to establish the severity of the consequences it caused and identify the gap in the system that allowed it to happen. An adverse event is defined as an injury caused by medical treatment rather than the disease itself; thus, adverse events can be viewed as consequences of errors.

According to the cause of the adverse event, they are classified into:
\begin{itemize}
  \item \textbf{Preventable adverse events:} Due to an error in choosing or applying an accepted strategy.
  \item \textbf{Ameliorable adverse events:} An event that was not preventable but could have been less harmful if the strategy had been different.
  \item \textbf{Adverse events due to negligence:} Occurred due to inadequate or below-standard care.
\end{itemize}

Medical errors can have a wide range of consequences, from minor and temporary to serious and permanent. According to their severity, medical errors can be classified as follows:
\begin{enumerate}
  \item \textbf{Mild adverse events:} Errors that cause minimal or temporary harm to the patient, such as a mild allergic reaction to a medication or a small infection at an injection site.
  \item \textbf{Moderate adverse events:} Errors that cause significant but reversible harm to the patient, such as a bone fracture during a fall in the hospital or an adverse reaction to a medication that requires hospitalization.
  \item \textbf{Severe adverse events:} Errors that cause permanent or life-threatening harm to the patient, such as a brain injury during surgery or a severe allergic reaction causing anaphylactic shock.
  \item \textbf{Fatal adverse events:} Errors that result in the death of the patient, such as a fatal medication error or a serious nosocomial infection.
  \item \textbf{Near miss:} An adverse event that occurred due to an error but didn't cause any harm.
\end{enumerate}

\section{Contributing Factors to Medical Errors: A Multidimensional Analysis}
Over recent decades, healthcare systems worldwide have tried to reduce medical errors as much as possible, but despite immense efforts, they remain part of daily healthcare processes. To continue improving prevention, it is crucial to understand the reasons that can lead to medical errors and adverse events. After years of research, the causes can now be identified and grouped into three different categories: human, system, and patient-related. These categories involve components that interact with each other and between groups in complex and intricate ways, creating a susceptible environment that allows medical errors to occur at any step in the patient care process.

To develop effective prevention and mitigation strategies, it is crucial to understand the factors that lead to medical errors. Research in medicine and law has identified a wide range of elements that can increase the likelihood of these errors occurring.

\subsection{Human Factors: Healthcare Professionals}
Healthcare is almost universally seen as a noble and reputable field, but increasing tuition costs, long years of training, lack of recognition, non-competitive salaries, and poor work-life balance have decreased the number of interested candidates pursuing healthcare careers. Even in countries where personnel shortages are not a problem, institutions tend to offer the lowest possible compensation and maintain minimal staffing levels, making it difficult to attract and retain healthcare workers. The resulting shortage of personnel leads to chronic overwork among existing staff, with consequences that affect the entire system:

Health professionals, despite their training and experience, are human beings susceptible to errors. Fatigue, stress, lack of effective communication, and cognitive biases are some of the human factors that can compromise patient safety.

\begin{itemize}
  \item \textbf{Fatigue and Stress:} Excessive workload, long shifts, and lack of adequate rest can negatively affect the cognitive and physical performance of healthcare professionals, increasing the risk of errors. Fatigue can decrease attention, concentration, memory, and decision-making ability, while chronic stress can lead to emotional exhaustion and depersonalization, affecting response time, judgment, and the quality of care provided.

  \item \textbf{Lack of Communication:} Effective communication between members of the healthcare team is essential to ensure patient safety. Lack of clarity in information transmission during shift changes, poorly written instructions, ambiguous verbal orders, lack of coordination between different professionals involved in patient care, and linguistic or cultural barriers can lead to misunderstandings and errors.

  \item \textbf{Cognitive Biases:} Cognitive biases are systematic thinking patterns that can lead to erroneous judgments and hasty decisions. In the medical context, these biases can influence how professionals collect, interpret, and process clinical information, leading to diagnostic and treatment errors. Common cognitive biases in medical practice include confirmation bias (the tendency to seek information that confirms pre-existing beliefs), anchoring bias (the tendency to rely too heavily on the first information received), and availability bias (the tendency to overestimate the probability of events that are easily remembered).
\end{itemize}

\subsection{System-Related Factors: The Context of Health Care}
The healthcare system refers to all the organization, rules, and resources (software and hardware) present in a facility involved in the healthcare process. All these components can facilitate the occurrence of medical errors.

\begin{itemize}
  \item \textbf{Organization of the Health System:} The way the healthcare system is organized and managed can influence patient safety. Lack of clear protocols, fragmentation of care, lack of continuity of care, and lack of adequate supervision can increase the risk of errors. Additionally, pressure to reduce costs and increase efficiency can lead to work overload and staff reduction, which can compromise the quality of care.

  \item \textbf{Lack of Resources:} Lack of human, material, and financial resources can limit the ability of healthcare professionals to provide safe, quality care. Staff shortages can lead to work overload and burnout, while a lack of adequate medical equipment and supplies can lead to errors during diagnosis and treatment.

  \item \textbf{Inadequate Technology:} Medical technology, while it can improve efficiency and accuracy of care, can also be a source of errors if not used appropriately. Specifically, lack of training in the use of new technologies, poor interoperability between different information systems, and technical failures can contribute to medical errors.
\end{itemize}

\subsection{Patient-Related Factors: The Importance of Active Participation}
Despite the common belief that patients leave their health entirely in the hands of healthcare professionals, they actually play an active role in their care process. In fact, if patients do not engage, every attempt to help them will be futile. From describing their symptoms to adhering to treatment, patients must be involved and work toward their goals alongside providers to prevent medical errors.

\begin{itemize}
  \item \textbf{Lack of Adherence to Treatment:} Treatment adherence refers to the degree to which patients follow medical recommendations. Non-adherence can be due to various factors, such as lack of understanding of instructions, medication side effects, financial barriers, or lack of social support. It is the provider's responsibility to ensure that patients fully understand instructions and to work around patients' needs and barriers. Non-adherence can lead to complications and the need for additional treatments, increasing the risk of errors.

  \item \textbf{Poor Communication:} Effective communication between patients and healthcare professionals is essential to ensure safe and quality care. Patients should feel comfortable asking questions, expressing concerns, and sharing relevant information about their medical history and symptoms. Lack of communication can lead to misunderstandings, misdiagnoses, and inappropriate treatments.

  \item \textbf{Lack of Understanding:} Patients may have difficulty understanding complex medical information, which can impact their ability to make informed decisions about their health and follow treatment recommendations. Lack of understanding can be due to various factors, such as the use of medical jargon, lack of appropriate educational materials, or language or cultural barriers. Providers must ensure proper communication, explaining medical situations in the simplest way possible, being open to questions, and negotiating with patients to develop feasible care plans.
\end{itemize}

\section{Diagnostic Error: Definition and Types}
Diagnostic error (DE) is a complex and multifaceted problem that affects medical practice at all levels of care. Although medicine has advanced significantly in recent decades, the possibility of delayed, wrong, or missed diagnoses remains a concerning reality. The Institute of Medicine (IOM), now known as the National Academy of Medicine (NAM), defines diagnostic error as \textit{"the failure to establish an accurate and timely explanation of the patient's health problem or problems, or to communicate that explanation to the patient"}. This patient-centered definition emphasizes the importance of not only establishing a correct diagnosis but also doing so in a timely manner, especially for potentially life-threatening conditions.

The Society for Improving Diagnosis in Medicine (SIDM) proposes a classification of diagnostic errors into three main categories:

\begin{enumerate}
  \item \textbf{Missed or missing diagnosis:} When no explanation is found for the patient's symptoms, despite the diagnostic tests performed.
  
  \item \textbf{Incorrect diagnosis:} When the initial diagnosis turns out to be incorrect, and the true cause of the symptoms is discovered later.
  
  \item \textbf{Delayed diagnosis:} When the correct diagnosis is established, but with a significant delay that may have negatively affected the patient's prognosis or treatment.
\end{enumerate}

It is important to note that these categories are not mutually exclusive, and in many cases, a diagnostic error may involve a combination of them.

\section{Factors Influencing Diagnostic Errors in Medicine}
Medical diagnosis is the first goal in the care plan. To effectively treat a patient, the first step is determining the condition affecting them. Coming to a diagnosis is a complex process involving both patient and provider working together with available information, experience, knowledge, and diagnostic tools. Even with incredible advances in diagnostic procedures, diagnostic errors still occur and can have serious consequences, from delayed treatments to patient death. The causes of diagnostic errors are multifactorial and can be attributed to a combination of cognitive, system, and patient-related factors.

\subsection{Cognitive Factors: Providers}
Cognitive factors are defined as the mental processes that clinicians use to gather, interpret, and evaluate clinical information to make decisions. Even with years of training and experience, healthcare providers are susceptible to bias and affected by other limitations that can influence their judgment and lead to diagnostic errors.

\subsubsection{Cognitive Biases}
Cognitive biases are systematic patterns of thinking that can lead to deviations from rational judgment. In the context of medical diagnosis, some of the most common biases include:

\begin{itemize}
  \item \textbf{Confirmation bias:} The tendency to search for and interpret information that confirms a preconceived hypothesis, ignoring or minimizing information that contradicts it.
  
  \item \textbf{Anchor bias:} The tendency to fixate excessively on the first information received from the patient, even if it is incomplete or inaccurate, and to incorrectly adjust the diagnosis to the one that information pointed toward, even as new information becomes available.
  
  \item \textbf{Availability bias:} The tendency to overestimate the probability of diseases that are easier to remember or have been encountered recently, which can lead to missing less common diagnoses, perpetuating the false belief that the most common diagnosis is always the answer.
  
  \item \textbf{Overconfidence bias:} The tendency to overestimate one's own diagnostic capacity and underestimate the possibility of error.
\end{itemize}

\subsubsection{Heuristics}
Heuristics are mental shortcuts that allow doctors to make quick decisions in situations of uncertainty. Although they can be useful in clinical practice, they can also lead to errors if applied inappropriately. Some examples of heuristics include:

\begin{itemize}
  \item \textbf{Representativeness heuristic:} The tendency to diagnose a disease based on the similarity of the patient's symptoms to a typical case of a certain disease, without actively considering other possibilities.
  
  \item \textbf{Availability heuristic:} The tendency to diagnose diseases that are more common or have been found recently, without adequately considering the actual prevalence of the disease in the population.
\end{itemize}

\subsubsection{Limitations of Human Reasoning}
In addition to biases and heuristics, human reasoning has inherent limitations that can contribute to diagnostic errors. These limitations include:

\begin{itemize}
  \item \textbf{Limited information processing capacity:} Clinicians must process large amounts of clinical information in a short period, which can lead to errors due to cognitive overload.
  
  \item \textbf{Fatigue and stress:} Fatigue and stress can affect attention span, memory, and judgment, increasing the likelihood of errors.
  
  \item \textbf{Lack of knowledge or experience:} Doctors can make diagnostic errors if they do not have the knowledge or experience necessary to recognize a particular disease.
\end{itemize}

\subsection{System-Related Factors}
System-related factors are the characteristics of the work environment and the organization of the health system that may contribute to diagnostic errors.

\begin{itemize}
  \item \textbf{Time constraints:} The constant pressure and short time slots that healthcare professionals are subjected to during medical consultations are important factors that can lead to diagnostic errors. Providers often care for a large number of patients in a limited time, which can make it difficult to take a complete history and physical examination, as well as consider all possible diagnostic hypotheses.
  
  \item \textbf{Environmental pressure:} The constant pressure of caring for high volumes of patients, especially in departments with a consistently fast-paced environment, is very demanding for providers. Accompanied by multiple simultaneous stimuli and chronic fatigue, this can affect their diagnostic ability. Furthermore, the need to make quick decisions in emergency situations can lead to errors due to lack of proper reflection and analysis.
  
  \item \textbf{Poor communication and use of electronic tools:} Poor communication between different health professionals caring for the same patient can be an important cause of diagnostic errors. Failure to share relevant information, misinterpretation of test results, or lack of coordination in patient follow-up can lead to delays in diagnosis or misdiagnoses. Also, misuse of electronic medical records to track the patient's latest updates or failing to upload recent changes can lead to errors.
\end{itemize}

\subsection{Patient-Related Factors}
Patient-related factors may also influence the likelihood of diagnostic errors, not just through poor communication or lack of engagement. There are cases with rare presentations or uncommon diseases that can lead to medical errors.

\begin{itemize}
  \item \textbf{Complexity of the cases:} Some patients present with complex or atypical clinical symptoms, which can make diagnosis difficult. Rare diseases, unusual presentations of common diseases, or the presence of comorbidities can increase diagnostic uncertainty and the probability of error.
  
  \item \textbf{Communication:} The patient-provider relationship is a complex interaction. Patients need to build trust to openly share personal details with providers about their medical history. If they don't feel comfortable enough, they might not mention crucial information needed to make an accurate diagnosis, delaying the process or leading the provider to consider other probable causes.
\end{itemize}

\section{Overdiagnosis, Diagnostic and Therapeutic Cascades}
Overdiagnosis is an increasingly recognized phenomenon in modern medicine and refers to the diagnosis of a medical condition that, if undetected, would never have caused symptoms or affected the patient's health. Overdiagnosis can occur due to several factors, including overuse of screening tests, lowering thresholds to define diseases, and pressure to find explanations for the patient's symptoms.

Another negative outcome from overuse of screening tests is diagnostic and therapeutic cascades, which are series of events triggered by an incidental finding in a diagnostic test or by a side effect of a treatment.

The implications of both overdiagnosis and cascades are significant, mainly because they can lead to unnecessary treatment, which can be expensive, cause side effects, and create anxiety for the patient. They can also divert healthcare system resources that could be used to treat patients with real and potentially serious illnesses. Finally, they can create a false sense of security in the patient, leading them to ignore important symptoms of other diseases, believing that they're already being treated and in the process of getting better.

\section{Diagnostic Error in Primary Care}
Primary care providers are the first point of contact for most patients and are also responsible for continuing care after patients have been treated by specialists. They provide long-term care for a wide variety of patients with different levels of complexity, which makes primary care providers especially susceptible to diagnostic errors.

As the ones making referrals, diagnostic errors by primary care providers can have serious consequences, delaying proper diagnosis and treatment, or subjecting patients to unnecessary tests and therapies that carry their own risks. Given the importance of primary care as the foundation of the healthcare system, efforts to prevent medical errors should also be directed toward primary care settings, even when they may not face the same life-or-death decision-making scenarios as other specialties.

\section{Consequences for the Patient's Health}
Patients directly suffer the consequences of diagnostic errors, which can range from mild to severe and, in some cases, irreversible. They also carry a mental and emotional component that many patients never fully recover from, permanently changing their perception of the healthcare system and providers. The consequences can be divided into the following categories:

\begin{itemize}
  \item \textbf{Increased morbidity:} Morbidity refers to the presence of a disease or medical condition. Diagnostic errors can increase morbidity by delaying the start of appropriate treatment, providing incorrect treatment, or not providing treatment at all, which can lead to long-term complications and sequelae.
  
  \item \textbf{Increased mortality:} In severe cases, diagnostic errors can have fatal consequences. A study published in the British Medical Journal estimated that medical errors, including diagnostic errors, are the third leading cause of death in the United States.
  
  \item \textbf{Decreased quality of life:} Even when not fatal, diagnostic errors can significantly affect a patient's quality of life. Chronic pain, disability, anxiety, and depression are just some of the possible long-term consequences of a misdiagnosis or delayed diagnosis.
  
  \item \textbf{Mental and emotional impact:} For some, just visiting a doctor is already a stressful experience. Receiving a diagnosis can be relieving, but when it involves a life-impacting illness, it can cause significant emotional pain. Going through tests and treatments only increases this stress. It is devastating when the diagnosis turns out to be wrong and the patient has undergone unnecessary tests and treatments, and even worse when they did not receive life-saving measures. This can lead to long-term depression, anxiety, and permanently impact the patient's perception of the healthcare system, as well as create conflicts within the patient's support system.
\end{itemize}

\section{Economic Impact}
Diagnostic errors also have a significant economic impact, both for patients and the healthcare system. These costs may include:

\textbf{For the patient:}
\begin{itemize}
  \item \textbf{Additional medical expenses:} Misdiagnosis or late diagnosis can lead to unnecessary tests and treatments, increasing medical expenses for the patient and the healthcare system.
  
  \item \textbf{Loss of productivity:} Undiagnosed or misdiagnosed illnesses can lead to decreased work productivity, resulting in loss of income for the patient and their family.
\end{itemize}

\textbf{For the healthcare system:}
\begin{itemize}
  \item \textbf{Litigation costs:} In some cases, diagnostic errors can lead to medical negligence claims, resulting in legal and compensation costs for healthcare professionals and healthcare institutions.
  
  \item \textbf{Burden on the health system:} Diagnostic errors can cause misuse of resources in healthcare facilities and generate mistrust among the population, which can lead to significant losses for the facility and providers involved.
\end{itemize}

\begin{table}[htbp]
\centering
\caption{Impact of Medical Errors}
\begin{tabular}{p{0.3\textwidth}p{0.6\textwidth}}
\toprule
\textbf{Consequence} & \textbf{Description} \\
\midrule
Patient harm & It can manifest as physical harm, such as injuries or health complications, or as psychological harm, such as anxiety, depression, or loss of trust in the health system. \\
\midrule
Delay or avoidance of appropriate treatment & A wrong or late diagnosis can lead to the patient not receiving the necessary treatment in time, which can aggravate their condition and decrease their chances of recovery. \\
\midrule
Unnecessary or dangerous treatment & An incorrect diagnosis can result in the administration of treatments that the patient does not need, which may be ineffective or even harmful to their health. \\
\midrule
Psychological repercussions & A diagnostic error, especially a serious one, can have a significant emotional impact on the patient and their families, including anxiety, depression, post-traumatic stress, and loss of trust in health professionals. \\
\midrule
Financial implications & Medical errors can result in additional expenses for the patient and their family, such as additional treatment costs, loss of income due to inability to work, and legal expenses in the event of malpractice lawsuits. \\
\midrule
Malpractice Lawsuits & Patients affected by medical errors can file legal claims against the healthcare professionals or institutions involved, seeking compensation for damages suffered. \\
\midrule
Impact on the reputation of the professional and the institution & Medical errors, especially if made public, can damage the reputation of the healthcare professional and the institution where the error occurred, which can affect the trust of patients and the community at large. \\
\bottomrule
\end{tabular}
\end{table}

\section{Addressing Contributing Factors: Steps Towards Safer Health Care}
Preventing medical errors requires a multidimensional approach that addresses human, systemic, and patient-related factors. Some key strategies include:

\begin{itemize}
  \item \textbf{Improving Communication:} Encourage open and effective communication between members of the healthcare team, promoting a healthy work environment focused on patient safety. Implement open communication pathways between professionals and patients, including using clear and understandable language, actively listening, asking open-ended questions, showing empathy and validation, continuously checking patient understanding, and encouraging patient participation in decision-making.
  
  \item \textbf{Continuous Training:} Provide ongoing training to healthcare professionals on patient safety, effective communication, teamwork, and error management. Training in clinical reasoning and decision-making skills can help reduce cognitive biases and improve diagnostic accuracy. It is also important to keep professionals trained in electronic healthcare tools so they are aware of updates and modifications.
  
  \item \textbf{Healthcare System Support:} Improve the organization and management of the healthcare system, ensuring the availability of adequate resources, the implementation of clear protocols, and continuity of care. Foster a culture of safety in which mistakes are seen as opportunities for learning and improvement, rather than cause for blame or punishment.
  
  \item \textbf{Technology Implementation:} Use technology effectively to improve patient safety, such as electronic medical records, early warning systems, and decision support tools, as well as mandatory double checks for decision making. With advances in medicine and medical technology, it is easier to catch errors before they turn into adverse events.
  
  \item \textbf{Patient Empowerment:} Encourage the active participation of patients in their care by providing clear and understandable information about their disease and its treatment, and promoting adherence to treatment.
\end{itemize}

Preventing medical errors is an ongoing endeavor that requires the involvement of every participant in the care process. Once we understand the causes, we can make collective efforts to improve the healthcare system and take a patient-based approach in all decisions, bearing in mind that patient safety is not a destination but an everyday journey for providers.

Diagnostic errors represent a significant challenge in healthcare, negatively impacting patients' health and generating considerable costs for healthcare systems. Preventing these errors is an ethical and public health imperative that requires a multifaceted approach. This article explores various strategies aimed at minimizing the occurrence of diagnostic errors, focusing on improving doctor-patient communication, training in clinical reasoning and decision making, the use of diagnostic support tools, the implementation of error notification and learning systems, and the active participation of patients in the diagnostic process.

\section{Clinical Importance: Providers' Perspective}
Despite decades of effort, medical errors remain a common cause of morbidity and mortality in the United States and worldwide. As part of the ethical foundations of practicing medicine, the main goal for healthcare providers should be to "cause no harm," but medical errors happen even with the best intentions.

Most errors are not the fault of a single provider or group of providers; instead, they result from failures in the healthcare system that affect the care process, such as similarly spelled medications stored together, unstandardized dosage writing, absence of pharmacist supervision, or an unbalanced workload.

Errors can be prevented with all the strategies previously mentioned, but even then, the first step in learning the root cause of an error is reporting it. Currently, reporting an error is often avoided by healthcare professionals, especially if the consequences were mild or a near miss, because reporting can lead to severe sanctions and permanently affect a provider's career. Therefore, one of the main efforts should be toward embracing a system improvement culture instead of individual punishment.

Providers involved in medical errors should be held accountable, but they should also have open pathways to discuss the problem and share their thoughts on the root cause of the errors so that modifications can be implemented to prevent future adverse events. When the focus of correcting medical errors shifts from individual or group sanctions to foundational system modifications, we can actually prevent the same mistake from happening again by double-checking all steps in the chain of care. This perspective also allows providers to feel secure in their work environment, encouraging them to report issues rather than minimizing problems that can perpetuate the adverse event cycle.

Creating a safe work environment is essential to break down barriers that prevent underlying problems in healthcare organization from being fixed. It is crucial to understand that retaliating against healthcare professionals won't improve the system; it will only delay necessary changes to embrace a patient safety-centered healthcare model.

\section{Implementation of Error Notification and Learning Systems}
Implementing error reporting systems is essential to learn from previous mistakes and improve patient safety. These systems must be confidential and non-punitive, promoting a culture of safety and organizational learning. Errors must be analyzed systematically to identify root causes and develop effective prevention strategies.

Patient safety training should be an integral part of the education and training of health professionals. Students and residents must learn to identify, report, and analyze errors, and actively participate in improving patient safety.

\section{Patient Participation in the Diagnostic Process}
Active participation of patients in their own care is crucial to improve diagnostic accuracy and reduce errors. Patients need to feel safe sharing their concerns and should be encouraged to share details about their medical history, symptoms, and anything they feel is related to their current situation. Once a diagnosis is made, providers should always communicate in a timely and sensitive manner, explaining the findings in a way that is easy for the patient to understand, informing them about treatment options, risks, and benefits, while always giving them the opportunity to ask questions and express their preferences.

The use of electronic tools like electronic medical records systems and patient interfaces that patients can access anytime is an excellent way to empower them to participate in their care process. These tools provide accessible information, explanations, and ways to communicate with providers, and can even help patients provide information they might not feel comfortable sharing face-to-face, thereby improving the provider-patient relationship and lowering the chance of missing or mistaking a diagnosis.

\section{Ethical Considerations in the Management of Medical Errors}
As mentioned previously, despite the best efforts and intentions of medical providers, the practice of medicine is not exempt from errors and their consequences. Healthcare providers should take every possible step to prevent the occurrence of medical errors, but once they have occurred, ethical considerations must prevail when making decisions about managing adverse events.

\subsection{The Importance of Transparency and Open Communication with the Patient}
When an adverse event occurs, the most important step is transparent communication with the patient, showing respect and consideration, as these are the foundations of the provider-patient relationship. All errors must be communicated honestly and in a timely manner, allowing the patient to make decisions about the next steps required to recover their health.

Healthcare providers always have a duty to inform. It is understandable that in a highly competitive environment like medicine, acknowledging mistakes is incredibly difficult—it not only gives the feeling of inadequacy but also represents a failure to one's perceived self. Nevertheless, what must prevail is patient safety; therefore, healthcare professionals have the duty to inform, regardless of personal conflicts, hoping that adverse events can be addressed as soon as possible.

Despite the difficulty of communicating an error to the patient, this approach offers benefits for both parties:

\textbf{For the patient}, open communication can:
\begin{itemize}
  \item \textbf{Reduce anxiety and uncertainty:} Knowing what happened and why can help the patient better understand their situation and feel more in control.
  \item \textbf{Facilitate informed decision-making:} Understanding the consequences of the error and the available treatment options allows the patient to make informed decisions about their care.
  \item \textbf{Strengthen the provider-patient relationship:} Honesty and transparency can foster trust and mutual respect, which is essential for an effective therapeutic relationship.
\end{itemize}

\textbf{For the health professional}, open communication can:
\begin{itemize}
  \item \textbf{Relieve emotional burden:} Admitting a mistake and apologizing can help a doctor deal with guilt and prevent burnout.
  \item \textbf{Encourage learning and improvement:} Recognizing errors and analyzing their causes can help doctors learn from them and take steps to prevent future errors.
  \item \textbf{Improve reputation:} Honesty and transparency can strengthen patients' trust in the doctor and the health institution once they have taken steps to correct the error.
\end{itemize}

\section{Improving Healthcare Team Outcomes}
All healthcare personnel are part of the same team with the shared goal of restoring patients to health. One of the biggest barriers in the medical field is the lack of communication between providers—not just doctors, nurse practitioners, or physician assistants, but also medical assistants, pharmacologists, lab technicians, and every professional who has direct or indirect contact with the patient. They all need to be aware of updates and communicate effectively with one another to ensure patient safety.

Implementing tools such as checklists, double checks for prescriptions, EMR notes, and medication charts that all team members can access can drastically reduce medical errors. These tools help avoid double medication administration, medication interactions, unnecessary testing, and facilitate confirmation of progress. They also allow verification of verbal orders, which are always prone to misunderstandings. All healthcare team members must continuously train and remain up to date with electronic systems and tool updates, using them in the best interest of the patient.

Additionally, accreditation agencies and training programs should continually focus on improving patient safety and teaching ways to reduce common medical errors. A collaborative interprofessional team comprising these agencies, clinicians, and administrators can identify inherent system and process deficiencies and develop corrective measures to reduce the incidence of medical errors in the healthcare industry.

\section{The Role of Ethics Committees in the Management of Medical Errors}
Ethics committees play a crucial role in the management of medical errors, providing guidance and support to both patients and healthcare professionals. These committees are composed of experts in ethics, medicine, law, and other relevant disciplines. Their primary function is to promote ethical, quality healthcare and provide unbiased analysis and resolution of ethical conflicts.

Ethics committees can help analyze and resolve ethical conflicts that arise in relation to medical errors. These conflicts may involve difficult decisions about treatment, disclosure of information, or allocation of resources. The ethics committee provides an objective perspective and helps the parties involved reach fair and ethical solutions. Ethics committees also contribute to the development of policies and procedures to prevent and manage medical errors. These policies may include protocols for reporting errors, communicating with patients, and implementing corrective measures. The ethics committee helps ensure that these policies respect patients' rights.

Ethics committees serve as safeguards that promote integrity and accountability in healthcare. Below are relevant functions that highlight their importance:

\subsection{Functions of the Ethics Committees}
\begin{enumerate}
  \item \textbf{Protection of Human Rights:} Ethics committees are essential to protect the rights of patients and ensure that medical practices are carried out ethically. Their creation is justified by the need to navigate the use of human organs and critical end-of-life decisions, highlighting their role in preventing abuse of power and errors in medical care.

  \item \textbf{Evaluation of Research Projects:} Health research ethics committees are responsible for evaluating projects to ensure the protection of participants and scientific integrity. This includes reviewing research protocols involving patient participation, ensuring that ethical practices are followed and that risks to patients are minimized.

  \item \textbf{Confidence Building:} These committees not only address ethics in research but also foster trust between healthcare professionals and patients. By establishing a framework for ethical discussion, committees help resolve conflicts and make consistent decisions, which are essential for the management of medical errors.

  \item \textbf{Independence and Autonomy:} The independence of ethics committees is crucial to their effectiveness. They must operate without outside influences to fairly evaluate cases of medical errors and ensure that decisions are made based on sound ethical principles.
\end{enumerate}

Ethics committees are essential in the management of medical errors, as they protect the rights of patients, evaluate ethics in research, and foster trust in the health system. Their independence and ability to address ethical dilemmas are critical to improving the quality of healthcare and preventing future errors. Preventing and managing medical errors is a complex challenge that requires a multifaceted approach. Ethics plays a crucial role in this process, guiding actions and decisions toward protecting patients and promoting safe, quality healthcare. Transparency, open communication, the duty to inform, and the role of ethics committees are key elements in addressing medical errors in an ethical and responsible manner, promoting a culture of safety and learning in the healthcare field.

\section{Legal Liability for Diagnostic Errors: A Legal Analysis}
The medical process, particularly diagnosis, is subject to the uncertainty inherent in human knowledge and the variability of biological responses. This reality creates the possibility of errors which, under certain circumstances, can generate legal liability for healthcare professionals.

The doctor-patient relationship is configured as a service contract in which the doctor undertakes to provide professional services with due diligence. Jurisprudence has established that this obligation is one of means, not results—that is, the doctor does not guarantee the patient's cure but rather commits to using all available means to achieve that goal. In the event of failure to fulfill this obligation, whether by action or omission, the doctor may incur civil liability. Diagnostic error can be one manifestation of this non-compliance.

In cases of medical liability due to diagnostic error, the burden of proof falls on the patient or their family members. They must demonstrate that the doctor acted negligently or recklessly, that damage occurred, and that there is a causal relationship between the medical action and the damage suffered. Proving medical negligence or recklessness can be complex, as it requires establishing that the doctor deviated from the "lex artis ad hoc"—the body of knowledge and practices accepted by the medical community at the time of the action. This typically requires medical experts to evaluate the professional's performance against the standards of the profession.

\subsection{Concepts of Fault, Negligence, and Recklessness}
Fault, in the field of medical civil liability, refers to the lack of diligence or care in professional performance. It manifests in two forms:

\begin{itemize}
  \item \textbf{Negligence:} Omission of due diligence—the doctor fails to do what they should according to professional standards. For example, not performing necessary diagnostic tests based on the patient's symptoms.
  
  \item \textbf{Imprudence:} Hasty or reckless action without taking due precautions. For example, performing a medical procedure without having the necessary training or experience.
\end{itemize}

For civil liability to exist, the fault must be serious. A simple diagnostic error without negligence or recklessness is not sufficient to generate liability. Jurisprudence has recognized the inherent difficulty in medical diagnosis and has established that error alone does not constitute liability.

Legal liability for diagnostic errors is a complex and delicate issue. The doctor has the obligation to act with due diligence, in accordance with the "lex artis ad hoc," but cannot be required to guarantee a result. The burden of proof falls on the patient, who must demonstrate medical negligence or recklessness, the damage suffered, and the causal relationship between them. It is important to note that not every diagnostic error generates civil liability.

\section{Conclusion}
As a human-related science, medicine will always be prone to errors. When humans are involved, risk is inevitable. However, this does not mean that healthcare organizations, institutions, and professionals should not use every available resource to prevent errors from occurring.

The goal in medicine should always be the best outcome for the patient. Therefore, preventing medical errors remains a significant endeavor for all participants in the care process. The first step is recognizing the gaps in the system that allow errors to occur in order to correct issues and prevent recurrence.

To achieve this, the entire healthcare system should aim to transition from a punitive to a learning approach, viewing error reports as opportunities to improve and provide high-quality care without compromising the security of a positive work environment for healthcare providers. Medicine with a patient-centered approach is always the goal when it comes to error prevention.

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