Editing Medical error (section)

=== System and process design ===
In 2000, The Institute of Medicine released "[[To Err Is Human (report)|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.<ref name=toerr />

Poor communication and unclear lines of authority of physicians, nurses, and other care providers are also contributing factors.<ref name=cause /> 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.<ref name=Gardner>{{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 }}</ref>

Other factors include the impression that action is being taken by other groups within the institution, reliance on automated systems to prevent error.,<ref name=barcode>{{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 }}</ref> and inadequate systems to share information about errors, which hampers analysis of contributory causes and improvement strategies.<ref>{{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 }}</ref>
Cost-cutting measures by hospitals in response to reimbursement cutbacks can compromise [[patient safety]].<ref>{{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 }}</ref>
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.<ref>{{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 }}</ref>
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 [[JCAHO|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 analysis|root cause]] of over half the serious adverse events in accredited hospitals.<ref>{{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 }}</ref> Other leading causes included inadequate assessment of the patient's condition, and poor leadership or training.