The Domino Effect of Medical Errors

Dr Samer Ellahham MD, CPHQ, CMQ, EFQM, FACC, FAHA

By Dr Samer Ellahham MD, CPHQ, CMQ, EFQM, FACC, FAHA

AHA Hospital Accreditation Science Committee Member. Regional Chair, Middle East, Patient Safety Movement Foundation. Cleveland Clinic Caregiver. Senior Cardiovascular Consultant. Heart and Vascular Institute Advisor. Quality and Safety Institute Advisor. Cleveland Clinic Abu Dhabi.

3 Aug 2020

The Domino Effect of Medical Errors

Citation: Ellahham, S. (2019). The Domino Effect of Medical Errors. American Journal of Medical Quality, 34(4), 412-413.

Medical errors (MEs) are often defined as “an act of omission or commission in planning or execution that contributes or could contribute to an unintended result.”1,2 MEs are associated with a high rate of morbidity, mortality, and economic burden on the community. The Centers for Disease Control and Prevention stated that MEs are the third most common cause of death in the United States.3 The total annual cost of measurable MEs in the United States was found to be more than $1 billion in 2009.4

A ME negatively affects all stakeholders in the health care industry, creating a domino effect (Figure 1). Patients, their families, health care team members, health care organizations and management, and the community equally share the burden of the ME.

For example, in an ill-fated incident (September 2010), a critical care nurse in Seattle Children’s Hospital accidentally gave a sick baby a fatal dose of calcium chloride. The incident resulted in the death of the 8-month-old child; the nurse was later fired. The nurse was refused work despite having 27 years of pediatric experience. Seven months later, the nurse committed suicide.5 Moreover, the integrity of the hospital was questioned and it had to pay a hefty fine. The community’s faith in the nursing profession was shaken and the risks associated with the nursing profession were elucidated.

This example highlights that ill effects of MEs are not limited to patients, families, and health care providers (HCPs). Rather, they extend beyond and affect supporting staff, the institution, and the community.

Figure 1. Domino effect of a medical error.

Need to Look Beyond the “Second Victim”

Customarily, the aftermath of a ME is focused on the first victim (ie, patient and their family) and the second victim, that is, HCPs (ie, doctors, nurses).6,7 However, the other stakeholders of the health care system are often neglected, thus increasing the chances of future MEs. This practice indicates an urgent need for a comprehensive approach that extends beyond the first and second victims to manage and reduce MEs.

The entire health care system works as a single entity; hence, if one component falls, all the others fall, creating a domino effect. Identifying the vulnerable component of the health care framework and providing adequate support to it can possibly break this cycle and protect other members from the possible collapse. Hence, after a ME, it is important that support and help be extended to all vulnerable members of the team and not be limited to just the first and second victims.

Other Victims of a Medical error

Health Care Support Staff: Third victim

Health care support staff is an umbrella term used for clinic support staff, diagnostic staff, hospital staff, and administrative staff. Negligence by any member of this team could possibly lead to serious MEs. Unfortunately, support measures that can possibly help support staff are not available in a health care framework. In the worst cases, the affected person is often bullied, and peer support also is not extended. Such practices result in low self-esteem, lack of confidence, and guilt in the affected member.

Health Care Organization: Fourth Victim

The health care organization is the fourth victim of a ME. Any medical malpractice adversely affects the reputation of the institution. There is loss of faith in the integrity of the institution and an increased economic burden related to lawsuits for medical malpractice.

Community: Fifth Victim

A community comprises the other members of the health care fraternity and people in general who might require health care services in future. In any instance of ME, other HCPs developed a negative bias toward the specific procedure or drug involved in the incident. Till evidence is available, a HCP chooses to exempt said procedure/drug, which in certain cases can negatively affect the patient’s recovery. Likewise, patients also lose their faith in the health care system.

Holistic Approach to Reduce Medical Errors

A multicomponent intervention is required to reduce the incidence of MEs. This includes, but is not limited to, the following:

  • A positive safety approach: As a standard practice, all forms of MEs should be avoided after the first Generating checklists, dos and don’ts, or red flags should be practiced, safeguarding that every member of the team is well-versed in his/her role and abides strictly by it. Policy makers, patients, and families often are not aware of important safety issues; hence, they should be guided and informed as and when needed.
  • Effective communication: Communication is the key component in the health care system. Any incidence of ME should be highlighted to raise awareness about the issue. Information should be disseminated widely and bias toward the incident or person should be strictly avoided.8 Modern communications tools such as reminders, alerts, instant messaging apps, and emails should be used for fast and effective
  • Timely monitoring and documentation: Timely monitoring of a ME significantly reduces negative outcomes. Any instance of errors should be well documented as early as Checklists should be used to improve quality of care and to enforce a structured form of record keeping. All records should be made easily accessible to concerned members and the authority.
  • Training the workforce: Education and training of HCPs is important to manage and minimize potential risks of Education about patient safety, multi- disciplinary and interprofessional education, and continuing medical education are some important tools for training the workforce.8 Additionally, training in soft skills and medical ethics also should be provided to all the team members.
  • Extending support: Peer support such as outreach calls, invitation/opening, listening, reflecting, reframing, sense-making, coping, closing, and resources/referrals are some effective ways to extend support to the vulnerable team These measures help an individual cope after the unfortunate event and help develop a sense of shared organizational responsibility for team member well-being and patient safety.
  • Knowledge sharing: ME experiences should be shared openly in the medical fraternity via research and publications. This might help reduce any similar incidents and identify the gaps in patient.


  • Focus on all the possible victims of MEs and extend support to all.
  • Conduct studies and audits of medical negligence
  • cases to identify emerging causes of MEs.
  • Develop better federal health care policies to compensate for medical negligence and to reduce the economic burden of MEs.



1. World Health Organization. Medication Errors: Technical Series on Safer Primary Care. Geneva, Switzerland: World Health Organization. dle/10665/252274/9789241511643-eng.pdf?sequence=1. Accessed September 5, 2018.
2. Grober ED, Bohnen JMA. Defining medical error. Can J Surg. 2005;48(1):39-44.
3. Makary MA, Daniel M. Medical error—the third leading cause of death in the US. BMJ. 2016;353:i2139.
4. David G, Gunnarsson CL, Waters HC, Horblyuk R, Kaplan HS. Economic measurement of medical errors using a hos- pital claims database. Value Health. 2013;16:305-310.
5. Saavedra SM. Remembering Kimberly Hiatt: A casualty of second victim syndrome. How a single mistake from an experienced critical care nurse caused her to end her life. Published November 25, 2015. Accessed September 22, 2018.
6. Wu AW. Medical error: the second victim. The doctor who makes the mistake needs help too. BMJ.2000;320:726-727.
7. Scott SD, Hirschinger LE, Cox KR, et al. Caring for our own: deploying a systemwide second victim rapid response team. Jt Comm J Qual Patient Saf. 2010;36:233-240.
8. Conway J, Federico F, Stewart K, Campbell M. Respectful Management of Serious Clinical Adverse Events. IHI Innovation Series White Paper. Cambridge, MA: Institute for Healthcare Improvement; 2010.

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