Physician Reporting Compared with Medical-Record Review to Identify Adverse Medical Events

O’Neil, Anne; Petersen, Laura A.; Cook, Evelyn; Bates, David W.; Lee, T H; Brennan, Troyen A.

doi:10.7326/0003-4819-119-5-199309010-00004

Cited by 281 publications

(175 citation statements)

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“…22 O'Neil et al compared chart review with confidential housestaff self-reporting through electronic mail or written report deposited in a collection box. 4 The two methods turned up similar numbers of events, though the events reported by housestaff proved more amenable to preventive efforts. Selfreport also turned out to be substantially less expensive than chart review.…”

Section: Methods Of Detection and Reportingmentioning

confidence: 99%

“…2 Other studies have produced similarly striking results. [3][4][5] Since 1994 there have been a number of efforts to study adverse events in medicine and establish strategies to reduce them, including the founding of the National Patient Safety Foundation as a branch of the American Medical Association, the revision of the policy on medical error reporting of the Joint Commission on Accreditation of Healthcare Organizations, and the establishment of a patient safety improvement initiative at the Veterans Administration. 6,7 Where does EM fit into this?…”

Section: Medical Error In the 1990smentioning

confidence: 99%

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Promoting Patient Safety and Preventing Medical Error in Emergency Departments

Schenkel

2000

Academic Emergency Medicine

134

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Abstract. An estimated 108,000 people die each year from potentially preventable iatrogenic injury. One in 50 hospitalized patients experiences a preventable adverse event. Up to 3% of these injuries and events take place in emergency departments. With long and detailed training, morbidity and mortality conferences, and an emphasis on practitioner responsibility, medicine has traditionally faced the challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners. Yet no matter how well trained and how careful health care providers are, individuals will make mistakes because they are human. In general medicine, the study of adverse drug events has led the way to new methods of error detection and error prevention. A combination of chart reviews, incident logs, observation, and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order review. In emergency medicine (EM), error detection has focused on subjects of high liability: missed myocardial infarctions, missed appendicitis, and misreading of radiographs. Some system-level efforts in error prevention have focused on teamwork, on strengthening communication between pharmacists and emergency physicians, on automating drug dosing and distribution, and on rationalizing shifts. This article reviews the definitions, detection, and presentation of error in medicine and EM. Based on review of the current literature, recommendations are offered to enhance the likelihood of reduction of error in EM practice.

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Section: Methods Of Detection and Reportingmentioning

confidence: 99%

Section: Medical Error In the 1990smentioning

confidence: 99%

Promoting Patient Safety and Preventing Medical Error in Emergency Departments

Schenkel

2000

Academic Emergency Medicine

134

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“…The reasons for this variation are likely multifactorial, but the reasons may include different patient populations (illness severity, number and type of prescriptions) clinical practice variation, lack of uniformity of definitions, the processes under investigation (e.g., prescription, transcription), methods of reporting and the culture of the different centres reporting their data. 2,25,64,65 The lack of standard definitions and reporting techniques make comparisons across organizations, regions or countries difficult. 2 The single multicountry study included in our analysis did not report medication error rates across different countries.…”

Section: Organizationmentioning

confidence: 99%

Medication errors in critical care: risk factors, prevention and disclosure

Camiré

Moyen²,

Stelfox³

2009

Canadian Medical Association Journal

151

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Key points• Medication reconciliation may improve patient safety in the intensive care unit, and an updated list of medications should be maintained, including long-standing medications, the reasons for starting new medications and their planned stop dates and the reasons for discontinuing or holding old medications.• Engaging pharmacists in inpatient rounds in the intensive care unit may decrease the risk of adverse drug events.

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“…Although some research has demonstrated that a physician reporting system can be efficacious in a teaching hospital, the fact that there were no significant differences in the mean number of reports following interventional efforts is not unexpected (ONeil et al, 1993). There is much in the literature to support the fact that educational efforts to promote reporting do not make a difference in the amount of reporting (Berwick, 1996;CuUen et.…”

Section: Medical Errors 28mentioning

confidence: 91%

An Error Reduction Initiative

Underwood¹

2001

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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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Physician Reporting Compared with Medical-Record Review to Identify Adverse Medical Events

Abstract: An adverse event identification strategy based on physician self-referral uncovers as many adverse events as does a record review and is less costly. In addition, physician-identified events are more likely to be preventable and, thus, are targets for quality improvement.

Cited by 281 publications

References 0 publications

Promoting Patient Safety and Preventing Medical Error in Emergency Departments

Promoting Patient Safety and Preventing Medical Error in Emergency Departments

Medication errors in critical care: risk factors, prevention and disclosure

An Error Reduction Initiative

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