Study on Medical errors

In a recent report published in the Annals of Internal Medicine Missed and Delayed Diagnoses in the Ambulatory Setting: A Study of Closed Malpractice Claims -- Gandhi et al. 145 (7): 488 -- Annals of Internal Medicine, it was concluded that diagnostic errors that harm patients are typically the result of multiple breakdowns and individual and system factors. Awareness of the most common types of breakdowns and factors could help efforts to identify and prioritize strategies to prevent diagnostic errors.

This study, I think, is the beginning of really defining problems that are almost always multifactorial. It is rarely just a simple single oversight or error on an individual but a general breakdown in procedures and processes.

A recent example is the coumadin overdose at Methodist Hospital in the neonatal department. There were multiple chances to catch the error and for some reason, all of them seemed to fail, be overlooked or ignored.

Complacency with routines is sometimes the cause of these errors. This is why routine orders, critical pathways, defined treatments often create a laxity in critical thinking and leads to careless oversight. “Cookbook Medicine” as some doctors refer to it may help meet governmental standards for documentation of things, but it is not the sole answer to eliminate errors.

The report states that poor documentation, scheduling problems and miscommunication played a role in the errors, and it added that these findings reinforce the need for system interventions that reduce reliance on memory, force consideration of alternative diagnostic plans or second opinions, and provide clinical-decision support systems.