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Published on: February 16, 2011
The Perfect Storm: Exam of a Medical Error and Factors Contributing to Its Possible Escalation
1From the Johns Hopkins Bayview Medical Center, Baltimore, Maryland.
Objective:
After an initial medical misadventure, failure of recognition and continuing factors that could perpetuate the error are examined.
Methods:
A critical evaluation of the continuum of care after the initial error was conducted through chart review and comparison to published standards.
Results:
Analysis of the continuum of care after the original error demonstrated numerous system failures that should have alerted the providers to the initial error.
Discussion:
Technology, electronic medical records, lack of critical communications, and short cuts have the potential to not recognize patient care safety issues and potential harm.
Conclusions:
Medical errors are multifactorial. Blame casting and accusations are not productive. Critical analysis of systems/processes, current technology, eliminating shortcuts, and critical communications may increase patient safety.
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