Annals of Emergency Medicine
Volume 51, Issue 3 , Pages 251-261.e1 , March 2008

Characteristics of Patient Care Management Problems Identified in Emergency Department Morbidity and Mortality Investigations During 15 Years

Received 18 November 2006 ,Revised 14 June 2007 ,Accepted 25 June 2007.

References 

  1. 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;324:370–376
  2. Leape LL, Brennan TA, Laird N, et al. The nature of adverse events in hospitalized patients: results of the Harvard Medical Practice Study II. N Engl J Med. 1991;324:377–384
  3. Thomas EJ, Studdert DM, Burstin HR, et al. Incidence and types of adverse events and negligent care in Utah and Colorado. Med Care. 2000;38:261–271
  4. Wilson RM, Runciman WB, Gibberd RW, et al. The Quality in Australian Health Care Study. Med J Aust. 1995;163:458–471
  5. Vincent C, Neale G, Woloshynowych M. Adverse events in British hospitals: preliminary retrospective record review. BMJ. 2001;322:517–519
  6. Forster AJ, Asmis TR, Clark HD, et al. Ottawa Hospital Patient Safety Study: incidence and timing of adverse events in patients admitted to a Canadian teaching hospital. CMAJ. 2004;170:1235–1240
  7. In:  Kohn LT,  Corrigan JM,  Donaldson MS editor. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000;
  8. Committee on Quality of Health Care in AmericaInstitute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001;
  9. Fassett WE. Patient Safety and Quality Improvement Act of 2005. Ann Pharmacother. 2006;40:917–924
  10. Clinton HR, Obama B. Making patient safety the centerpiece of medical liability reform. N Engl J Med. 2006;354:2205–2208
  11. Landrigan CP, Rothschild JM, Cronin JW, et al. Effect of reducing interns’ work hours on serious medical errors in intensive care units. N Engl J Med. 2004;351:1838–1848
  12. Cosby KS, Croskerry P. Patient safety: a curriculum for teaching patient safety in emergency medicine. Acad Emerg Med. 2003;10:69–78
  13. Croskerry P, Sinclair D. Emergency medicine: a practice prone to error?. Can J Emerg Med. 2001;3:271–276
  14. Committee on the Future of Emergency Care in the United States Health SystemInstitute of Medicine. Hospital-Based Emergency Care: At the Breaking Point. Washington, DC: National Academies Press; 2006;
  15. Cosby KS. A framework for classifying factors that contribute to error in the emergency department. Ann Emerg Med. 2003;42:815–823
  16. Vincent C, Taylor-Adams S, Stanhope N. Framework for analysing risk and safety in clinical medicine. BMJ. 1998;316:1154–1157
  17. Reason J. Human Error. Cambridge, England: Cambridge University Press; 1990;
  18. Croskerry P. Diagnostic failure: a cognitive and affective approach. In:  Henriksen K,  Battles JB,  Marks ES, et al. editor. Advances in Patient Safety: From Research to Implementation. Vol 2:Rockville, MD: Agency for Healthcare Research and Quality; 2005;p. 241–254AHRQ Publication No. 05-0021-2
  19. Caplan RA, Posner KL, Cheney FW. Effect of outcome on physician judgments of the appropriateness of care. JAMA. 1991;265:1957–1960
  20. Henriksen K, Kaplan H. Hindsight bias, outcome knowledge and adaptive learning. Qual Saf Health Care. 2003;12(suppl II):ii46–ii50
  21. Senders JW, Moray NP. Human Error (Cause, Prediction, and Reduction): Analysis and Synthesis. Hillsdale, NJ: Lawrence Erlbaum Associates, Inc; 1991;
  22. Woolf SH, Kuzel AJ, Dovey SM, et al. A string of mistakes: the importance of cascade analysis in describing, counting, and preventing medical errors. Ann Fam Med. 2004;2:317–326
  23. Kuhn GJ. Diagnostic errors. Acad Emerg Med. 2002;9:740–750
  24. Schiff GD, Kim S, Abrams R, et al. Diagnosing diagnostic errors: lessons from a multi-institutional collaborative project. In:  Henriksen K,  Battles JB,  Marks ES, et al. editor. Advances in Patient Safety: From Research to Implementation. Vol 2:Rockville, MD: Agency for Healthcare Research and Quality; 2005;p. 255–278AHRQ Publication No. 05-0021-2
  25. Croskerry P. Achilles heels of the ED: delayed or missed diagnoses. ED Leg Lett. 2003;14:109–120
  26. Stiell A, Forster AJ, Stiell IG, et al. Prevalence of information gaps in the emergency department and the effect on patient outcomes. CMAJ. 2003;169:1023–1028
  27. Davies JM. Team communication in the operating room. Acta Anaesthesiol Scand. 2005;49:898–901
  28. Jain M, Miller L, Belt D, et al. Decline in ICU adverse events, nosocomial infections and cost through a quality improvement initiative focusing on teamwork and culture change. Qual Saf Health Care. 2006;15:235–239
  29. Behara R, Wears RL, Perry SJ, et al. A conceptual framework for studying the safety of transitions in emergency care. In:  Henriksen K,  Battles JB,  Marks ES, et al. editor. Advances in Patient Safety: From Research to Implementation. Vol 2:Rockville, MD: Agency for Healthcare Research and Quality; 2005;p. 309–3321AHRQ Publication No. 05-0021-2
  30. Croskerry P. Achieving quality in clinical decision making: cognitive strategies and detection of bias. Acad Emerg Med. 2002;9:1184–1204
  31. Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med. 2003;78:775–780
  32. Croskerry P. Cognitive forcing strategies in clinical decisionmaking. Ann Emerg Med. 2003;41:110–120
  33. Croskerry P. The cognitive imperative: thinking about how we think. Acad Emerg Med. 2000;7:1223–1231
  34. Graber M. Metacognitive training to reduce diagnostic errors: ready for prime time?. Acad Med. 2003;78:781
  35. Elstein AS, Schwarz A. Clinical problem solving and diagnostic decision making: selective review of the cognitive literature. BMJ. 2002;324:729–732
  36. Kassirer JP, Kopelman RI. Learning Clinical Reasoning. Baltimore, MD: Williams & Wilkins; 1991;
  37. Graber M, Gordon R, Franklin N. Reducing diagnostic errors in medicine: what’s the goal?. Acad Med. 2002;77:981–992
  38. Graber ML, Franklin N, Gordon R. Diagnostic error in internal medicine. Arch Intern Med. 2005;165:1493–1499
  39. Garg AX, Adhikari NK, McDonald H, et al. Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: a systematic review. JAMA. 2005;293:1223–1238
  40. Bates DW, Kuperman GJ, Wang S, et al. Ten commandments for effective clinical decision support: making the practice of evidence-based medicine a reality. J Am Med Inform Assoc. 2003;10:523–530
  41. Bond WF, Deitrick LM, Arnold DC, et al. Using simulation to instruct emergency medicine residents in cognitive forcing strategies. Acad Med. 2004;79:438–446
  42. Vincent C, Taylor-Adams S, Chapman EJ. How to investigate and analyse clinical incidents: Clinical Risk Management and Association of Litigation and Risk Management protocol. BMJ. 2000;320:777–781
  43. Kassirer JP, Kopelman RI. Cognitive errors in diagnosis: instantiation, classification, and consequences. Am J Med. 1989;86:433–441
  44. Wang MC, Hyun JK, Harrison M, et al. Redesigning health systems for quality: lessons from emerging practices. Jt Comm J Qual Patient Saf. 2006;32:599–611
  45. Ross L. The intuitive psychologist and his shortcomings: distortions in the attribution process. In:  Berkowitz L editors. Advances in Experimental Social Psychology. New York, NY: Academic Press; 1977;p. 174–221
  46. Banja J. Medical Errors and Medical Narcissism. Sudbury, MA: Jones and Bartlett Publishers; 2005;
  47. Conway JB, Weingart SN Agency for Healthcare Research and Quality Morbidity and Mortality Rounds Web site. Organizational change in the face of highly public errors (I. The Dana-Farber Cancer Institute experience). Accessed January 26, 2007 http://www.webmm.ahrq.gov/perspective.aspx?perspectiveID=3
  48. Kachalia A, Gandhi TK, Poupolo AL, et al. Missed and delayed diagnoses in the emergency department: a study of closed malpractice claims from 4 liability insurers. Ann Emerg Med. 2007;49:196–205
  49. White AA, Wright SW, Blanco R, et al. Cause-and-effect analysis of risk management files to assess patient care in the emergency department. Acad Emerg Med. 2004;11:1035–1041

 Supervising editor: Robert L. Wears, MD, MSAuthor contributions: KSC and RR conceived the study and obtained funding. KSC, RR, JS, and RDS designed the study. KSC, LP, CR, JS, S Sherman, IN, EC, ML, and S Schabowski were responsible for data acquisition. KSC, RR, IA, and RDS analyzed and interpreted the data. KSC and RR drafted the article and all authors contributed substantially to its revision. KSC, RR, IA, and RDS were responsible for statistical analysis. RR, LP, CR, JS, S Sherman, IN, EC, ML, S Schabowski, IA, and RDS provided administrative, technical, or material support. KSC and RR were responsible for overall study supervision. KSC and RR had full access to all the data and take responsibility for the integrity of the data and the accuracy of the data analysis. KSC takes responsibility for the paper as a whole.Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article, that might create any potential conflict of interest. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement. This study was funded in part by the Agency for Healthcare Research and Quality, grant number 5 P20 HS011552, and the Department of Emergency Medicine, Cook County Hospital (Stroger).Publication date: Available online October 15, 2007.

PII: S0196-0644(07)01252-8

doi: 10.1016/j.annemergmed.2007.06.483

Annals of Emergency Medicine
Volume 51, Issue 3 , Pages 251-261.e1 , March 2008