TY - JOUR
T1 - Beyond the medical record
T2 - Other modes of error acknowledgment
AU - Rosenthal, Marilynn M.
AU - Cornett, Patricia L.
AU - Sutcliffe, Kathleen M.
AU - Lewton, Elizabeth
N1 - Funding Information:
This work was supported by grants from the Office of the Vice President for Research, University of Michigan (Log no. 4148, OVPR, December 21, 1999), and the Office of Research and Sponsored Programs, University of Michigan—Dearborn, 2000.
PY - 2005/5
Y1 - 2005/5
N2 - BACKGROUND: Studies before and since the 1999 Institute of Medicine report have noted the limitations of using medical record reporting for reliably quantifying and understanding medical error. Quantitative macro analyses of large datasets should be supplemented by small-scale qualitative studies to provide insight into micro-level daily events in clinical and hospital practice that contribute to errors and adverse events and how they are reported. DESIGN: The study design involved semistructured face-to-face interviews with residents about the medical errors in which they recently had been involved and included questions regarding how those errors were acknowledged. OBJECTIVE: This paper reports the ways in which medical error is or is not reported and residents' responses to a perceived medical error. PARTICIPANTS: Twenty-six residents were randomly sampled from a total population of 85 residents working in a 600-bed teaching hospital. MEASUREMENTS: Outcome measures were based on analysis of cases residents described. Using Ethnograph and traditional methods of content analysis, cases were categorized as Documented. Discussed, and Uncertain. RESULTS: Of 73 cases. 30 (41.1%) were formally acknowledged and Documented in the medical record; 24 (32.9%) were addressed through Discussions but not documented; 19 cases (26%) cases were classified as Uncertain. Twelve cases Involved medication errors, which were acknowledged in different categories. CONCLUSIONS: The supervisory discussion, the informal discussion, and near-miss contain important information for improving clinical care. Our study also shows the need to improve residents' education to prepare them to recognize and address medical errors.
AB - BACKGROUND: Studies before and since the 1999 Institute of Medicine report have noted the limitations of using medical record reporting for reliably quantifying and understanding medical error. Quantitative macro analyses of large datasets should be supplemented by small-scale qualitative studies to provide insight into micro-level daily events in clinical and hospital practice that contribute to errors and adverse events and how they are reported. DESIGN: The study design involved semistructured face-to-face interviews with residents about the medical errors in which they recently had been involved and included questions regarding how those errors were acknowledged. OBJECTIVE: This paper reports the ways in which medical error is or is not reported and residents' responses to a perceived medical error. PARTICIPANTS: Twenty-six residents were randomly sampled from a total population of 85 residents working in a 600-bed teaching hospital. MEASUREMENTS: Outcome measures were based on analysis of cases residents described. Using Ethnograph and traditional methods of content analysis, cases were categorized as Documented. Discussed, and Uncertain. RESULTS: Of 73 cases. 30 (41.1%) were formally acknowledged and Documented in the medical record; 24 (32.9%) were addressed through Discussions but not documented; 19 cases (26%) cases were classified as Uncertain. Twelve cases Involved medication errors, which were acknowledged in different categories. CONCLUSIONS: The supervisory discussion, the informal discussion, and near-miss contain important information for improving clinical care. Our study also shows the need to improve residents' education to prepare them to recognize and address medical errors.
KW - Counting medical errors
KW - Medical error
KW - Medical error acknowledgement
KW - Medical mistake
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U2 - 10.1111/j.1525-1497.2005.0098.x
DO - 10.1111/j.1525-1497.2005.0098.x
M3 - Article
C2 - 15963161
AN - SCOPUS:22144486301
SN - 0884-8734
VL - 20
SP - 404
EP - 409
JO - Journal of general internal medicine
JF - Journal of general internal medicine
IS - 5
ER -