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Submitted: 29 Jan 2025
Revision: 26 Feb 2025
Accepted: 20 May 2025
ePublished: 02 Jun 2025
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  Abstract View: 11

Quality and Safety

Original Article

Identifying Factors Contributing to Medical Errors: A Qualitative Study

Fatemeh Leyci ORCID logo, Faramarz Pourasghar* ORCID logo

1 Department of Health Policy and Management, School of Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran

Abstract

Background. Medical errors present a significant challenge in healthcare systems, impacting patient safety and the quality of care. This study aimed to identify and prioritize the factors contributing to medical errors at Alzahra Teaching Hospital in Tabriz, Iran.

Methods. This qualitative study employed an inductive content analysis approach and utilized multiple methods, including document reviews, focus group discussions, and expert panels. A purposive heterogeneous sampling method was used to select participants from various healthcare professional groups (including physicians, nurses, and midwives) with diverse work experience, age, and gender, representing a wide range of perspectives and experiences. To enhance the study's rigor, member checking was conducted. To prioritize the identified factors, an expert panel (11 members with over five years of experience) rated the importance of each factor on a scale of 1 to 10. The average scores were calculated, and factors were ranked accordingly.

Results. The analysis identified 11 main categories, 45 themes, and 80 subthemes. The most significant category, provider-related factors, included a lack of knowledge and skills. Other categories involved communication failures, poor organizational culture, high workload, and outdated equipment. A total of 25 healthcare professionals (13 physicians, six nurses, and six midwives) participated in the study. The main categories (factors), in order of importance, included healthcare providers (10 themes), communication and information (five themes), organizational issues (eight themes), work environment (five themes), documentation (two themes), tasks (six themes), equipment (six themes), patients (four themes), and other categories including error reporting, and financial/legal issues (each comprising two themes).

Conclusion. Findings indicate that care provider-related factors, especially lack of knowledge and skills, have the greatest impact on medical errors. To reduce these errors, it is recommended to design continuous education programs for healthcare staff, strengthen teamwork culture and interdepartmental communication, increase staffing, and upgrade medical equipment. These measures can significantly improve patient safety and quality of care.

Keywords: Medical Error, Hospital, Patient Safety

Extended Abstract

Background

Medical errors represent one of the most critical challenges facing healthcare systems worldwide, with profound implications for patient safety and the overall quality of healthcare services. These errors compromise patient outcomes and erode public trust in healthcare institutions. Addressing the root causes of medical errors is essential for improving healthcare delivery and ensuring patient safety. This study was conducted to identify and prioritize the factors contributing to medical errors based on their significance at Al-Zahra Educational Hospital in Tabriz, Iran. By understanding these factors, targeted interventions can be designed to mitigate risks and enhance the quality of care.

Methods

This qualitative study employed a multi-method approach, including document reviews, focus group discussions (FGDs), and an expert panel, to explore factors contributing to medical errors. The study population consisted of healthcare professionals (physicians, nurses, and midwives) from Al-Zahra Educational Hospital in Tabriz, Iran. Data were collected through FGDs conducted between June and September 2023. Participants were purposively selected to ensure diversity in professional roles, experience, age, and gender. Each session lasted 30–45 minutes and followed a semi-structured interview protocol. Discussions were audio-recorded, transcribed, and analyzed using thematic content analysis. The analysis involved:

1. Familiarization: Repeatedly reviewing transcripts to ensure accuracy and understand the content.

2. Initial coding: Identifying and coding key concepts line-by-line.

3. Theme development: Grouping codes into broader themes and sub-themes.

4. Refinement and validation: Refining themes and conducting member checking to enhance credibility.

In November 2023, an expert panel of 11 members with expertise in patient care and safety reviewed and ranked the identified factors based on their perceived impact. Factors were rated on a scale of 1 to 10, and average scores were calculated for ranking. Ethical approval was obtained from Tabriz University of Medical Sciences (Code: IR.TBZMED.REC.1401.786), and all participants provided informed consent. This multi-method approach ensured the study's robustness and reliability.

Results

The study involved 25 healthcare professionals, including 13 physicians, six nurses, and six midwives. Through a rigorous analysis of the data, 11 main categories, 45 themes, and 80 subthemes were identified. The most significant category was provider-related factors, which included critical issues such as a lack of knowledge and skills among healthcare providers. Other important categories included communication failures, poor organizational culture, high workload, and the use of outdated equipment. The main categories, ranked in order of importance, were as follows:

1. Provider-related factors (10 themes),

2. Communication and information-related factors (five themes),

3. Organizational factors (eight themes),

4. Work environment-related factors (five themes),

5. Documentation-related factors (two themes),

6. Task-related factors (six themes),

7. Equipment-related factors (six themes),

8. Patient-related factors (four themes),

9. Other categories, including error reporting, and financial/legal issues (each comprising two themes).

These findings highlight the multifaceted nature of medical errors and the need for a comprehensive approach to address them.

Conclusion

The findings of this study underscore the critical role of provider-related factors, particularly the lack of knowledge and skills, in contributing to medical errors. To effectively reduce these errors, several evidence-based interventions are recommended. These include implementing continuous training programs to enhance healthcare providers’ knowledge and skills, fostering teamwork and improving interdepartmental communication, increasing the number of healthcare personnel to alleviate excessive workloads, and upgrading outdated medical equipment. By addressing these factors, healthcare institutions can significantly improve patient safety, enhance the quality of care, and restore public trust in the healthcare system. This study provides valuable insights for policymakers and healthcare administrators to design targeted strategies for reducing medical errors and promoting a safer healthcare environment.

Practical Implications of Research

1. Enhancing Healthcare Staff Awareness: The need for continuous education to update medical knowledge and reduce medical errors.

2. Strengthening Patient Safety Culture: Improving team communication and safety culture to minimize errors.

3. Utilizing Information Technology: Enhancing documentation systems and the transfer of medical information.

4. Improving Working Conditions: Addressing physical and social environments to reduce stress and increase the accuracy of healthcare staff.

These measures, when implemented together, can significantly reduce medical errors and enhance patient safety.

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