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What is an error?
T P Hofer1, E A Kerr, R A Hayward
1Department of Veterans Affairs, VA Center for Practice Management and Outcomes Research, VA Ann Arbor Healthcare System, Ann Arbor, Mich., USA. thofer@umich.edu
Effective Clinical Practice : ECP
|January 11, 2001
Summary
Medical errors need clear definitions linking process failures to patient harm. Efforts to reduce errors should prioritize those with the greatest impact on patient outcomes and be cost-effective.
Area of Science:
- Healthcare Quality Improvement
- Patient Safety Research
- Medical Error Analysis
Background:
- The Institute of Medicine's "To Err is Human" report highlighted medical error reduction as a critical healthcare priority.
- Significant efforts have been made across the U.S. healthcare system to address medical errors.
Purpose of the Study:
- To identify and analyze existing definitions of medical error.
- To determine the primary challenges in accurately measuring medical errors.
- To provide recommendations for advancing the field of medical error research and reduction.
Main Methods:
- A comprehensive review of medical literature.
- Inclusion of relevant studies from sociology and industrial psychology.
Main Results:
- Current definitions of medical error often lack a direct link to patient harm.
- Few studies have reliably measured medical errors, and their measurement reliability is often undescribed.
- The relationship between medical errors and adverse patient events remains under-examined.
- The utility of analyzing latent system errors via case studies or root cause analysis is not well-established.
Conclusions:
- Medical error should be defined by process failures demonstrably linked to adverse patient outcomes.
- Error reduction strategies must be proportional to their impact on patient outcomes (morbidity, mortality, satisfaction) and prevention costs.
- The medical error and quality improvement movements require a unified, rigorous epidemiologic approach to establish causality.