We have an opportunity to use the momentum generated from the
Institute of Medicine report on medical errors (1) and other groups (2) to
improve medical education. We recently used personal examples to increase
awareness of the significance of errors in medicine.
We showed a videotape on errors in medicine to the graduating class of
medical students. The tape was the keynote address of the 1999 Institute
for Healthcare Improvement National Forum on Quality Improvement in Health
Care. After viewing the tape we asked the students to close their eyes to
both maintain anonymity and increase response; and to raise their hands if
they have been exposed to medical errors. We asked, a) In your experience,
have you seen a medical error that resulted in anything from no harm to
death? Response: 100%. b) How many of those resulted in major harm or
death? Response: 30/67 (45%; 95% confidence interval [CI], 33% to 57%). c)
How many of those have you been personally involved with or have first
hand information? Response: 6/67 (9%; 95% CI, 2% to 16%).
Students then described, in writing, an error that resulted in death or
major harm. We typed all comments and analyzed the responses. The
agreement between two independent raters for the type of error was
moderate (kappa = 0.55, p<_0.001 _3="_3" disagreement="disagreement" was="was" resolved="resolved" by="by" consensus.="consensus." p="p"/>We found that errors fell in five categories: decision-making,
medications, procedural, system, and others.
First, errors in decision
making were noted in 12/62 responses (19%; 95% CI, 10% to 29%). Examples:
wrong diagnosis, pregnant patient sent home after blunt abdominal trauma.
Next, medication errors accounted for 18/62 responses (29%; 95% CI, 18% to
40%). Examples: prescription for Celebrex Ò instead of Celexa Ò, long
acting medication crushed.
The third category, procedural errors accounted
for 7/62 responses (11%; 95% CI, 3% to 19%). Examples: technical error due
to insufficient training, pneumothorax due to inadequate technique.
Fourth, system errors accounted for 15/62 responses (24%; 95% CI, 14% to
35%). Examples: inability to obtain medical records, too much autonomy,
staffing shortage.
Finally, other types of errors accounted for 10/62
responses (16%; 95% CI, 7% to 25%). Examples: fear of correcting a
superior, inadequate blood sampling.
We further categorized their written
comments as errors that resulted in death in 14.5% (9/62) (moderate
agreement, kappa = 0.57, p<_0.001 and="and" we="we" deemed="deemed" errors="errors" as="as" preventable="preventable" in="in" _69="_69" _43="_43" _62="_62" fair="fair" agreement="agreement" kappa="0.38," p="p"/>How do we interpret that 45% of graduating students are aware of an
incident that has resulted in major harm or death, yet 9% had first hand
information? If such estimates are accurate and representative, they are
astounding. However, we believe that students are talking about those
errors in informal ways. Medical errors are not the product of recent news
hysteria, they occur here - at home. We are committed to facing the
challenges in medical education to change the culture of blame and to
provide a safe forum to discuss and learn from our errors. We suspect that
the reader will discover similar findings at their own institutions.
References
1. Kohn LT, Corrigan JM, Donaldson MS. Eds. To Err is Human, Building
a Safer Health System. Institute of Medicine. Washington, DC: National
Academy Press; 1999.
2. Wu A. Medical error: the second victim. BMJ 2000; 320: 726-727.
3. Sackett DL, Haynes RB, Guyatt GH, Tugwell P. Clinical
Epidemiology: A Basic Science for Clinical Medicine. 2nd ed. Boston, Mass:
Little, Brown and Co; 1991.
Address Correspondence:
Carlos Estrada, MD, MS
Clinical Information and Support Office - Support Building,
University Health Systems,
2100 Stantonsburg Road
Greenville, NC 27835-6028
USA
Carlos A. Estrada MD, MS. Associate Medical Director
James Carter, MD, FACS. Medical Director
Clyde Brooks, MD. Associate Medical Director
Clinical Information and Support Office - Support Building,
University Health Systems,
2100 Stantonsburg Road,
Greenville, NC 27835-6028
USA
Ann C. Jobe, MD, MSN. Senior Associate Dean
Brody School of Medicine at East Carolina University
600 Moye Blvd,
Greenville, NC 27858
USA
Rapid Response:
Medical Errors and Medical Education
We have an opportunity to use the momentum generated from the
Institute of Medicine report on medical errors (1) and other groups (2) to
improve medical education. We recently used personal examples to increase
awareness of the significance of errors in medicine.
We showed a videotape on errors in medicine to the graduating class of
medical students. The tape was the keynote address of the 1999 Institute
for Healthcare Improvement National Forum on Quality Improvement in Health
Care. After viewing the tape we asked the students to close their eyes to
both maintain anonymity and increase response; and to raise their hands if
they have been exposed to medical errors. We asked,
a) In your experience,
have you seen a medical error that resulted in anything from no harm to
death? Response: 100%.
b) How many of those resulted in major harm or
death? Response: 30/67 (45%; 95% confidence interval [CI], 33% to 57%).
c)
How many of those have you been personally involved with or have first
hand information? Response: 6/67 (9%; 95% CI, 2% to 16%).
Students then described, in writing, an error that resulted in death or
major harm. We typed all comments and analyzed the responses. The
agreement between two independent raters for the type of error was
moderate (kappa = 0.55, p<_0.001 _3="_3" disagreement="disagreement" was="was" resolved="resolved" by="by" consensus.="consensus." p="p"/>We found that errors fell in five categories: decision-making,
medications, procedural, system, and others.
First, errors in decision
making were noted in 12/62 responses (19%; 95% CI, 10% to 29%). Examples:
wrong diagnosis, pregnant patient sent home after blunt abdominal trauma.
Next, medication errors accounted for 18/62 responses (29%; 95% CI, 18% to
40%). Examples: prescription for Celebrex Ò instead of Celexa Ò, long
acting medication crushed.
The third category, procedural errors accounted
for 7/62 responses (11%; 95% CI, 3% to 19%). Examples: technical error due
to insufficient training, pneumothorax due to inadequate technique.
Fourth, system errors accounted for 15/62 responses (24%; 95% CI, 14% to
35%). Examples: inability to obtain medical records, too much autonomy,
staffing shortage.
Finally, other types of errors accounted for 10/62
responses (16%; 95% CI, 7% to 25%). Examples: fear of correcting a
superior, inadequate blood sampling.
We further categorized their written
comments as errors that resulted in death in 14.5% (9/62) (moderate
agreement, kappa = 0.57, p<_0.001 and="and" we="we" deemed="deemed" errors="errors" as="as" preventable="preventable" in="in" _69="_69" _43="_43" _62="_62" fair="fair" agreement="agreement" kappa="0.38," p="p"/>How do we interpret that 45% of graduating students are aware of an
incident that has resulted in major harm or death, yet 9% had first hand
information? If such estimates are accurate and representative, they are
astounding. However, we believe that students are talking about those
errors in informal ways. Medical errors are not the product of recent news
hysteria, they occur here - at home. We are committed to facing the
challenges in medical education to change the culture of blame and to
provide a safe forum to discuss and learn from our errors. We suspect that
the reader will discover similar findings at their own institutions.
References
1. Kohn LT, Corrigan JM, Donaldson MS. Eds. To Err is Human, Building
a Safer Health System. Institute of Medicine. Washington, DC: National
Academy Press; 1999.
2. Wu A. Medical error: the second victim. BMJ 2000; 320: 726-727.
3. Sackett DL, Haynes RB, Guyatt GH, Tugwell P. Clinical
Epidemiology: A Basic Science for Clinical Medicine. 2nd ed. Boston, Mass:
Little, Brown and Co; 1991.
Address Correspondence:
Carlos Estrada, MD, MS
Clinical Information and Support Office - Support Building,
University Health Systems,
2100 Stantonsburg Road
Greenville, NC 27835-6028
USA
Carlos A. Estrada MD, MS.
Associate Medical Director
James Carter, MD, FACS.
Medical Director
Clyde Brooks, MD.
Associate Medical Director
Clinical Information and Support Office - Support Building,
University Health Systems,
2100 Stantonsburg Road,
Greenville, NC 27835-6028
USA
Ann C. Jobe, MD, MSN.
Senior Associate Dean
Brody School of Medicine at East Carolina University
600 Moye Blvd,
Greenville, NC 27858
USA
Competing interests: No competing interests