Resident Perceptions of Medical Errors in the Emergency Department
2003; Wiley; Volume: 10; Issue: 12 Linguagem: Inglês
10.1111/j.1553-2712.2003.tb00004.x
ISSN1553-2712
AutoresStephen Schenkel, Rahul K. Khare, Marilynn M. Rosenthal, Kathleen M. Sutcliffe, Elizabeth Lewton,
Tópico(s)Clinical Reasoning and Diagnostic Skills
ResumoAcademic Emergency MedicineVolume 10, Issue 12 p. 1318-1324 Free Access Resident Perceptions of Medical Errors in the Emergency Department Stephen M. Schenkel MD, MPP, Corresponding Author Stephen M. Schenkel MD, MPP University of Michigan, Department of Emergency Medicine, Ann Arbor, MIAddress for correspondence and reprints: Stephen Schenkel, MD, MPP, Emergency Medical Services, University of Maryland, 419 W. Redwood St., Baltimore, MD 21201. Fax: 734-763-9298; e-mail: [email protected].Search for more papers by this authorRahul K. Khare MD, Rahul K. Khare MD University of Michigan, Department of Emergency Medicine, Ann Arbor, MISearch for more papers by this authorMarilynn M. Rosenthal PhD, Marilynn M. Rosenthal PhD Department of Behavioral Sciences, Ann Arbor, MISearch for more papers by this authorKathleen M. Sutcliffe PhD, Kathleen M. Sutcliffe PhD School of Business Administration, Ann Arbor, MISearch for more papers by this authorElizabeth L. Lewton PhD, MPH, Elizabeth L. Lewton PhD, MPH School of Business Administration, Ann Arbor, MISearch for more papers by this author Stephen M. Schenkel MD, MPP, Corresponding Author Stephen M. Schenkel MD, MPP University of Michigan, Department of Emergency Medicine, Ann Arbor, MIAddress for correspondence and reprints: Stephen Schenkel, MD, MPP, Emergency Medical Services, University of Maryland, 419 W. Redwood St., Baltimore, MD 21201. Fax: 734-763-9298; e-mail: [email protected].Search for more papers by this authorRahul K. Khare MD, Rahul K. Khare MD University of Michigan, Department of Emergency Medicine, Ann Arbor, MISearch for more papers by this authorMarilynn M. Rosenthal PhD, Marilynn M. Rosenthal PhD Department of Behavioral Sciences, Ann Arbor, MISearch for more papers by this authorKathleen M. Sutcliffe PhD, Kathleen M. Sutcliffe PhD School of Business Administration, Ann Arbor, MISearch for more papers by this authorElizabeth L. Lewton PhD, MPH, Elizabeth L. Lewton PhD, MPH School of Business Administration, Ann Arbor, MISearch for more papers by this author First published: 28 June 2008 https://doi.org/10.1197/S1069-6563(03)00559-1Citations: 29AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Abstract Objectives: To evaluate resident experience and perceptions of medical error associated with emergency department (ED) care. Methods: Using a semistructured interview protocol, three researchers interviewed 26 randomly selected medical, surgical, and obstetrics residents regarding medical error. The authors chose a 16-case subset of incidents involving ED care for initial review. Interview transcripts were reviewed iteratively to draw out recurrent categories and themes. Two investigators separately analyzed all cases to ensure common understanding and agreement. Results: Most cases involved misdiagnosis, misread radiographs, or inappropriate disposition. Two thirds of the case patients died or experienced delays in care. Residents felt that the complexity of the patients, as well as the complexity of their own jobs, contributed to error. Attending supervision, nurse evaluation, and additional physician involvement all were noted to be important checks within the hospital system. Residents most often held the ED responsible for error. In addition, they deemed themselves, their teams, and their lack of training responsible. Though residents often discussed events with their admitting teams, follow-up with the ED or other associated individuals was uncommon. The findings revealed seven common themes that include factors contributing to errors, checks and adaptations, and follow-up of the event. Conclusions: Residents are aware of medical error and able to recall events in detail. Whereas events are discussed among inpatient teams, little information finds its way back to the ED, potentially resulting in misunderstandings between departments and hindering learning from events. In-depth interviewing allows a nuanced and detailed approach to error analysis. References 1 Institute of Medicine. To Err is Human; Building a Safer Health System. Washington DC : National Academy Press, 1999. 2 The Wrong Patient. New York Times. June 4, 2002. 3 Croskerry P.. The cognitive imperative: thinking about how we think. Acad Emerg Med. 2000; 7: 1223– 31. 4 Schenkel S.. Promoting patient safety and preventing medical error in emergency departments. Acad Emerg Med. 2000; 7: 1204– 22. 5 Henneman PL, Fordyce J., Blank D., et al. Errors in a busy ED [abstract]. Acad Emerg Med. 2002; 9: 400– 1. 6 Shapiro MJ, Simmons WN, Wright RO, et al. Can medical errors and near misses reported to an emergency department anonymous error reporting system be identified through chart review? [abstract] Acad Emerg Med. 2002; 9: 401. 7 Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study I. N Engl J Med. 1991; 324: 370– 6. 8 O'Neil AC, Peterson LA, Cook EF, Bates DW, Lee TH, Brennan TA. Physician reporting compared with medical-record review to identify adverse medical events. Ann Intern Med. 1993; 119: 370– 6. 9 Wu AW, Folkman S., McPhee SJ, Lo B.. Do house officers learn from their mistakes J Am Med Assoc. 1991; 265: 2089– 94. 10 Newman MC. The emotional impact of mistakes on family physicians. Arch Fam Med. 1996; 5: 71– 75. 11 Christensen JF, Levinson W., Dunn PM. The heart of darkness: the impact of perceived mistakes on physicians. J Gen Int Med. 1992; 7: 424– 31. 12 Fitzpatrick R., Boulton M.. Qualitative methods for assessing health care. Qual Health Care. 1994; 3: 107– 13. 13 Dingwall R., Murphy E., Watson P., Greatbatch D., Parker S.. Catching goldfish: quality in qualitative research. J Health Serv Res Pol. 1998; 3: 167– 72. 14 Mays N., Pope C.. Assessing quality in qualitative research. Br Med J. 2000; 302: 50– 2. 15 Pope C., Ziebland S., Mays N.. Analysing qualitative data. Br Med J 2000; 320: 114– 6. 16 Kuhn GJ. Diagnostic errors. Acad Emerg Med. 2002; 9: 740– 50. 17 Hobgood C., Hooker J., Shen P.. Medical error identification, disclosure, and reporting: are there differences between provider groups? [abstract] Acad Emerg Med. 2002; 9: 400. 18 Graber M., Gordon R., Franklin N.. Reducing diagnostic errors in medicine: what's the goal Acad Med. 2002; 77: 981– 92. 19 Karcz A., Korn R., Burke MC, et al. Malpractice claims against emergency physicians in Massachusetts: 1975-1993. Am J Emerg Med. 1996; 14: 341– 5. 20 Espinosa JA, Nolan TW. Reducing errors made by emergency physicians in interpreting radiographs: longitudinal study. Br Med J. 2000; 320: 737– 40. 21 Preston CA, Marr JJ, Amaraneni KK, Suthar BS. Reduction of "callbacks" to the ED due to discrepancies in plain radiograph interpretation. Am J Emerg Med. 1998; 16: 160– 2. 22 Howard SK, Gaba DM, Rosekind MR, Zarcone VP. The risks and implications of excessive daytime sleepiness in resident physicians. Acad Med. 2002; 10: 1019– 25. 23 Sox CM, Burstin HR, Orav EJ, et al. The effect of supervision of residents on quality of care in five university-affiliated emergency departments. Acad Med. 1998; 73: 776– 82. 24 Holliman CJ, Wuerz RC, Kimak MJ, et al. Attending supervision of nonemergency medicine residents in a university hospital ED. Am J Emerg Med. 1995; 13: 259– 61. 25 Cullen DJ, Bates DW, Small SD, Cooper JB, Nemeskal AR, Leape LL. The incident reporting system does not detect adverse drug events: a problem for quality improvement. J Qual Improv. 1995; 21: 541– 8. 26 Kraman SS, Hamm G.. Risk management: extreme honesty may be the best policy. Ann Intern Med. 1999; 131: 963– 7. 27 Goldberg RM, Kuhn G., Andrew LB, Thomas HA. Coping with medical mistakes and errors in judgment. Ann Emerg Med. 2002; 39: 287– 92. 28 Wears RL, Wu AW. Dealing with failure: the aftermath of errors and adverse events. Ann Emerg Med. 2002; 39: 344– 6. 29 Wu AW. Medical error: the second victim. Br Med J. 2000; 320: 726– 7. 30 Wu AW, Cavanaugh TA, McPhee SJ, Lo B., Micco GP. To tell the truth: ethical and practical issues in disclosing medical mistakes to patients. J Gen Int Med. 1997; 12: 770– 5. 31 Orlander JD, Barber TW, Fincke BG. The morbidity and mortality conference: the delicate nature of learning from error. Acad Med. 2002; 77: 1001– 6. 32 Weingart SN. House officer education and organizational obstacles to quality improvement. J Qual Improv. 1996; 22: 640– 6. 33 Leape LL. Error in Medicine. JAMA. 1994; 272: 1851– 7. 34 Weick E.. The reduction of medical errors through mindful interdependence. In: MM Rosenthal, KM Sutcliffe (eds). Medical Error: What Do We Know? What Do We Do? San Francisco : Jossey-Bass, 2002. 35 Hobgood CD, Ma OJ, Swart GL. Emergency medicine resident errors: identification and educational utilization. Acad Emerg Med. 2000; 7: 1317– 20. 36 Bates DW. Clinical crossroads: a 40-year-old woman who noticed a medication error. JAMA. 2001; 285: 3134– 40. 37 Audet AMJ, Hartman EE. Clinical crossroads update: a 40-year-old-woman who noticed a medication error, 1 year later. JAMA. 2002; 287: 3258. 38 Chassin MR, Becher EC. The wrong patient. Ann Intern Med. 2002; 136: 826– 33. 39 Sorokin R., Claves JL, Kane GC, Gottlieb JE. The near miss resident conference: understanding the barriers to confronting medical errors. Semin Med Prac. 2002; 5: 12– 19. 40 Vincent C.. Understanding and responding to adverse events. N Engl J Med. 2003; 348: 1051– 6. 41 Kovacs G., Croskerry P.. Clinical decision making: an emergency medicine perspective. Acad Emerg Med. 1999; 6: 947– 52. Citing Literature Supporting Information Tables 5 - 9 Files in this Data Supplement: Tables 5 - 9> Filename Description ACEM_1318_sm_Table_5-9.doc35 KB Supporting info item Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article. Volume10, Issue12December 2003Pages 1318-1324 ReferencesRelatedInformation
Referência(s)