Lyme disease, a growing public health problem in the United States, is also an increasing threat in Europe. Cases identified in a military community in West Germany are presented and problems of diagnosis and treatment discussed.
Public reporting burden for this collection of information Is estimated to average 1 hour per response, Including the time for reviewing Instructions, searching existing data sources, aatherino and maintaining the data needed, and completing and reviewing the collection of Information. Send comments regarding this burden estimate or any other aspect of this 5oiiectioS of information. Including suggestions for reducing this burden, to Washington Headquarters Services, Directorate for l"'o™«ion Operations and Repo^^^^ Davis Highway Suite 1204, Arlington, VA 22202-4302, and Medical errors kill many Americans each year. Information on sentinel events gathered at military hospitals is typically presented as numerator data without much analysis. Fearing litigation and blame, health care providers appear to be reluctant to report on "near misses" where errors have occurred, but not resulted in actual harm. Using a non-punitive approach, anesthesiologists championed a method to learn from errors in order to improve patient outcomes. This graduate management project involves analysis of trends and error rates in the risk management database of Winn Army Community Hospital. Numbers of incident reports were compared before and after educational interventions to increase voluntary reporting. Numbers of prescription edits were quantified and compared before and after default prescriptions were introduced to decrease errors. Recommendations were made about efforts which may best serve an effective error reduction initiative. 18814. SUBJECT TERMS I would like to thank COL George V. Masi for being a mentor, advisor and the best hospital Commander I have had the pleasure to know. Observing and learning from such a powerful role model has been a rewarding and memorable experience. MEDICAL ERRORS; INCIDENT REPORTSI would like to thank Ms. Kathy Dill, the Risk Manager at Winn Army CommunityHospital, for her patience, assistance and sharing. She is a source of inspiration in her care and concern for patient well-being.I would like to thank LTC Curt Hansen and MAJ Thomas Babb for their work with the pharmacy edits. This was not only enlightening, but also instrumental in terms of the conclusion and recommendations for future programs.I would like to thank CPT (P) Michael Heath for his advice, help and encouragement.I would like to thank COL (Ret.) Richard Harder for the books on leadership and for teaching me the mind-mapping technique. were compared before and after educational interventions to increase voluntary reporting.Numbers of prescription edits were quantified and compared before and after default prescriptions were introduced to decrease errors. Recommendations were made about efforts which may best serve an effective error reduction initiative.Medical Errors 4
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