Reducing medical errors and adverse events.

Medical errors account for ∼98,000 deaths per year in the United States. They increase disability and costs and decrease confidence in the health care system. We review several important types of medical errors and adverse events. We discuss medication errors, healthcare-acquired infections, falls, handoff errors, diagnostic errors, and surgical errors. We describe the impact of these errors, review causes and contributing factors, and provide an overview of strategies to reduce these events. We also discuss teamwork/safety culture, an important aspect in reducing medical errors.

[1]  D. Calfee,et al.  Crisis in hospital-acquired, healthcare-associated infections. , 2012, Annual review of medicine.

[2]  J. Vincent,et al.  Diagnosis, Management and Prevention of Ventilator-Associated Pneumonia , 2010, Drugs.

[3]  Michael A Rosen,et al.  On the front lines of patient safety: implementation and evaluation of team training in Iraq. , 2011, Joint Commission journal on quality and patient safety.

[4]  M. Kahn,et al.  Development, implementation, and evaluation of a comprehensive fall risk program. , 2011, Journal for specialists in pediatric nursing : JSPN.

[5]  T. Hoffmann,et al.  Patient education to prevent falls among older hospital inpatients: a randomized controlled trial. , 2011, Archives of internal medicine.

[6]  P. Pronovost,et al.  Collaborative Cohort Study of an Intervention to Reduce Ventilator-Associated Pneumonia in the Intensive Care Unit , 2011, Infection Control & Hospital Epidemiology.

[7]  R. Silverman,et al.  Prevention of 3 “Never Events” in the Operating Room: Fires, Gossypiboma, and Wrong-Site Surgery , 2011, Surgical innovation.

[8]  Pat Croskerry,et al.  Checklists to Reduce Diagnostic Errors , 2011, Academic medicine : journal of the Association of American Medical Colleges.

[9]  J. Gurwitz,et al.  Randomized trial of a warfarin communication protocol for nursing homes: an SBAR-based approach. , 2011, The American journal of medicine.

[10]  V. Steelman Sensitivity of detection of radiofrequency surgical sponges: a prospective, cross-over study. , 2011, American journal of surgery.

[11]  D. Maslove,et al.  Computerized Physician Order Entry in the Critical Care Environment: A Review of Current Literature , 2011, Journal of intensive care medicine.

[12]  Carol A. Keohane,et al.  Addition of electronic prescription transmission to computerized prescriber order entry: Effect on dispensing errors in community pharmacies. , 2011, American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists.

[13]  G. Norman,et al.  The Effectiveness of Cognitive Forcing Strategies to Decrease Diagnostic Error: An Exploratory Study , 2011, Teaching and learning in medicine.

[14]  Rhona Flin,et al.  Doctors' handovers in hospitals: a literature review , 2011, Quality and Safety in Health Care.

[15]  C. Divino,et al.  Integration of a formalized handoff system into the surgical curriculum: resident perspectives and early results. , 2011, Archives of surgery.

[16]  Gary Milavetz,et al.  Risk of adverse drug events in neonates treated with opioids and the effect of a bar-code-assisted medication administration system. , 2011, American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists.

[17]  Jenelle Matic,et al.  Review: bringing patient safety to the forefront through structured computerisation during clinical handover. , 2011, Journal of clinical nursing.

[18]  Mark L. Diana,et al.  Hospital computerized provider order entry adoption and quality: An examination of the United States. , 2011, Health care management review.

[19]  Rongwei Fu,et al.  Primary Care–Relevant Interventions to Prevent Falling in Older Adults: A Systematic Evidence Review for the U.S. Preventive Services Task Force , 2010, Annals of Internal Medicine.

[20]  Kabir Khanna,et al.  Exploring Relationships Between Hospital Patient Safety Culture and Adverse Events , 2010, Journal of patient safety.

[21]  J. Aucar,et al.  Use of an anatomic marking form as an alternative to the Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery. , 2010, American journal of surgery.

[22]  E. D. de Vries,et al.  Effect of a comprehensive surgical safety system on patient outcomes. , 2010, The New England journal of medicine.

[23]  Blackford Middleton,et al.  Fall prevention in acute care hospitals: a randomized trial. , 2010, JAMA.

[24]  Sallie J. Weaver,et al.  The Anatomy of Health Care Team Training and the State of Practice: A Critical Review , 2010, Academic medicine : journal of the Association of American Medical Colleges.

[25]  Sonya L Ranson,et al.  Teamwork training improves the clinical care of trauma patients. , 2010, Journal of surgical education.

[26]  D. Oliver,et al.  Preventing falls and fall-related injuries in hospitals. , 2010, Clinics in geriatric medicine.

[27]  James P Bagian,et al.  Briefing guide study: preoperative briefing and postoperative debriefing checklists in the Veterans Health Administration medical team training program. , 2010, American journal of surgery.

[28]  J. Neily,et al.  Association between implementation of a medical team training program and surgical mortality. , 2010, JAMA.

[29]  Peter J Pronovost,et al.  Establishing a global learning community for incident-reporting systems , 2010, Quality and Safety in Health Care.

[30]  Tamara van Gog,et al.  Effect of availability bias and reflective reasoning on diagnostic accuracy among internal medicine residents. , 2010, JAMA.

[31]  Sarah Henrickson Parker,et al.  Improving cardiac surgical care: a work systems approach. , 2010, Applied ergonomics.

[32]  Kevin Purdy,et al.  The Influence of Tall Man Lettering on Drug Name Confusion , 2010, Drug safety.

[33]  A. Vats,et al.  Postoperative Handover: Problems, Pitfalls, and Prevention of Error , 2010, Annals of surgery.

[34]  Hardeep Singh,et al.  Errors of Diagnosis in Pediatric Practice: A Multisite Survey , 2010, Pediatrics.

[35]  C. Longhurst,et al.  Decrease in Hospital-wide Mortality Rate After Implementation of a Commercially Sold Computerized Physician Order Entry System , 2010, Pediatrics.

[36]  Carol A. Keohane,et al.  Effect of bar-code technology on the safety of medication administration. , 2010, The New England journal of medicine.

[37]  Gabor D Kelen,et al.  An epidemiologic study of closed emergency department malpractice claims in a national database of physician malpractice insurers. , 2010, Academic emergency medicine : official journal of the Society for Academic Emergency Medicine.

[38]  J. Dettori,et al.  Avoiding Wrong Site Surgery: A Systematic Review , 2010, Spine.

[39]  David W Bates,et al.  Can electronic clinical documentation help prevent diagnostic errors? , 2010, The New England journal of medicine.

[40]  Kaveh G Shojania,et al.  Effect of point-of-care computer reminders on physician behaviour: a systematic review , 2010, Canadian Medical Association Journal.

[41]  M. Buljac-Samardžić,et al.  Interventions to improve team effectiveness: a systematic review. , 2010, Health policy.

[42]  E. Weinshel,et al.  Improving Handoff Communication: A Gastroenterology Fellowship Performance Improvement Project , 2010, The American Journal of Gastroenterology.

[43]  Peter J Pronovost,et al.  Sustaining reductions in catheter related bloodstream infections in Michigan intensive care units: observational study , 2010, BMJ : British Medical Journal.

[44]  Paul Sharek,et al.  Improved physician work flow after integrating sign-out notes into the electronic medical record. , 2010, Joint Commission journal on quality and patient safety.

[45]  Y. Donchin,et al.  Preoperative briefing in the operating room: shared cognition, teamwork, and patient safety. , 2010, Chest.

[46]  Peter Kaboli,et al.  The Veterans Affairs shift change physician-to-physician handoff project. , 2010, Joint Commission journal on quality and patient safety.

[47]  Christopher Beach,et al.  Improving handoffs in the emergency department. , 2010, Annals of emergency medicine.

[48]  Ngaire Kerse,et al.  Interventions for preventing falls in older people in nursing care facilities and hospitals. , 2010, The Cochrane database of systematic reviews.

[49]  Comilla Sasson,et al.  Rapid Response Teams: A Systematic Review and Meta-analysis. , 2010, Archives of internal medicine.

[50]  Emily Beth Devine,et al.  The impact of computerized provider order entry on medication errors in a multispecialty group practice , 2010, J. Am. Medical Informatics Assoc..

[51]  W. Berry,et al.  A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population , 2009, The New England journal of medicine.

[52]  J. Padmore,et al.  Residents’ and Attending Physicians’ Handoffs: A Systematic Review of the Literature , 2009, Academic medicine : journal of the Association of American Medical Colleges.

[53]  Jasmine Jones,et al.  Impact of a pharmacist-facilitated hospital discharge program: a quasi-experimental study. , 2009, Archives of internal medicine.

[54]  Geoff Norman,et al.  Dual processing and diagnostic errors , 2009, Advances in health sciences education : theory and practice.

[55]  Pat Croskerry,et al.  A universal model of diagnostic reasoning. , 2009, Academic medicine : journal of the Association of American Medical Colleges.

[56]  S. Reeves,et al.  Interprofessional collaboration: effects of practice-based interventions on professional practice and healthcare outcomes. , 2009, The Cochrane database of systematic reviews.

[57]  Mark V. Williams,et al.  Transitions of Care Consensus policy statement: American College of Physicians, Society of General Internal Medicine, Society of Hospital Medicine, American Geriatrics Society, American College Of Emergency Physicians, and Society for Academic Emergency Medicine. , 2009, Journal of hospital medicine.

[58]  A. Egberts,et al.  Medication Safety: Effect of Medication Reconciliation with and Without Patient Counseling on the Number of Pharmaceutical Interventions Among Patients Discharged from the Hospital , 2009, The Annals of pharmacotherapy.

[59]  Blake J. Lesselroth,et al.  Using consumer-based kiosk technology to improve and standardize medication reconciliation in a specialty care setting. , 2009, Joint Commission journal on quality and patient safety.

[60]  J. Cooper,et al.  Medication interventions for fall prevention in the older adult. , 2009, Journal of the American Pharmacists Association : JAPhA.

[61]  K. T. Fong,et al.  Surgical team behaviors and patient outcomes. , 2009, American journal of surgery.

[62]  Catherine L. Liang,et al.  Effect of an electronic medication reconciliation application and process redesign on potential adverse drug events: a cluster-randomized trial. , 2009, Archives of internal medicine.

[63]  C. Scholle,et al.  Ticket to Ride: Reducing Handoff Risk During Hospital Patient Transport , 2009, Journal of nursing care quality.

[64]  B. Flanagan,et al.  The teaching of a structured tool improves the clarity and content of interprofessional clinical communication , 2009, Quality & Safety in Health Care.

[65]  Lee Ann Riesenberg,et al.  Systematic Review of Handoff Mnemonics Literature , 2009, American journal of medical quality : the official journal of the American College of Medical Quality.

[66]  T. Manser Teamwork and patient safety in dynamic domains of healthcare: a review of the literature , 2009, Acta anaesthesiologica Scandinavica.

[67]  J. West "Ticket to ride": how useful is this new handoff tool? , 2009, Journal of healthcare risk management : the journal of the American Society for Healthcare Risk Management.

[68]  M. Makary,et al.  Impact of preoperative briefings on operating room delays: a preliminary report. , 2008, Archives of surgery.

[69]  G. Powell-Cope,et al.  Biomechanical Evaluation of Injury Severity Associated with Patient Falls from Bed , 2008, Rehabilitation nursing : the official journal of the Association of Rehabilitation Nurses.

[70]  E. Amato-Vealey,et al.  Hand-off communication: a requisite for perioperative patient safety. , 2008, AORN journal.

[71]  Helen Burstin,et al.  Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals , 2008, Infection Control & Hospital Epidemiology.

[72]  Donald L. Miller,et al.  Quality improvement guidelines for preventing wrong site, wrong procedure, and wrong person errors: application of the joint commission "Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery" to the practice of interventional radiology. , 2008, Journal of vascular and interventional radiology : JVIR.

[73]  Claude Deschamps,et al.  Incidence and characteristics of potential and actual retained foreign object events in surgical patients. , 2008, Journal of the American College of Surgeons.

[74]  Peter J Pronovost,et al.  Improving patient safety in intensive care units in Michigan. , 2008, Journal of critical care.

[75]  E. D. de Vries,et al.  The incidence and nature of in-hospital adverse events: a systematic review , 2008, Quality & Safety in Health Care.

[76]  Margaret A Dudeck,et al.  CDC/NHSN surveillance definition of health care-associated infection and criteria for specific types of infections in the acute care setting. , 2008, American journal of infection control.

[77]  L. Mion,et al.  Improving the Capture of Fall Events in Hospitals: Combining a Service for Evaluating Inpatient Falls with an Incident Report System , 2008, Journal of the American Geriatrics Society.

[78]  Catherine Sherrington,et al.  Cluster randomised trial of a targeted multifactorial intervention to prevent falls among older people in hospital , 2008, BMJ : British Medical Journal.

[79]  Marlene R. Miller,et al.  Reduction of catheter-associated bloodstream infections in pediatric patients: Experimentation and reality* , 2008, Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.

[80]  Mary Cooper,et al.  Managing the Prevention of Retained Surgical Instruments: What Is the Value of Counting? , 2008, Annals of surgery.

[81]  L. Mallak,et al.  Communicating in the "gray zone": perceptions about emergency physician hospitalist handoffs and patient safety. , 2007, Academic emergency medicine : official journal of the Society for Academic Emergency Medicine.

[82]  Janet Johnston,et al.  Getting Surgery Right , 2007, Annals of surgery.

[83]  Edna Zohar,et al.  Perioperative Patient Safety: Correct Patient, Correct Surgery, Correct Side—A Multifaceted, Cross-Organizational, Interventional Study , 2007, Anesthesia and analgesia.

[84]  R. Cumming,et al.  A Randomized, Controlled Trial of tai chi for the Prevention of Falls: The Central Sydney tai chi Trial , 2007, Journal of the American Geriatrics Society.

[85]  D. Oleynikov,et al.  Radio frequency identification (RFID) applied to surgical sponges , 2007, Surgical Endoscopy.

[86]  D. Cardo,et al.  Estimating Health Care-Associated Infections and Deaths in U.S. Hospitals, 2002 , 2007, Public health reports.

[87]  P. Pronovost,et al.  An intervention to decrease catheter-related bloodstream infections in the ICU. , 2006, The New England journal of medicine.

[88]  L. Nyberg,et al.  A multidisciplinary, multifactorial intervention program reduces postoperative falls and injuries after femoral neck fracture , 2006, Osteoporosis International.

[89]  E. Finkelstein,et al.  The costs of fatal and non-fatal falls among older adults , 2006, Injury Prevention.

[90]  Alex Macario,et al.  Initial clinical evaluation of a handheld device for detecting retained surgical gauze sponges using radiofrequency identification technology. , 2006, Archives of surgery.

[91]  K. Bani-Hani,et al.  Retained surgical sponges (gossypiboma). , 2005, Asian journal of surgery.

[92]  A. Localio,et al.  Role of computerized physician order entry systems in facilitating medication errors. , 2005, JAMA.

[93]  B. Trautner,et al.  Prevention of catheter-associated urinary tract infection , 2005, Current opinion in infectious diseases.

[94]  Robert L. Wears,et al.  A Conceptual Framework for Studying the Safety of Transitions in Emergency Care , 2005 .

[95]  L. Graff,et al.  Decreasing clinically significant adverse events using feedback to emergency physicians of telephone follow-up outcomes. , 2005, Annals of emergency medicine.

[96]  S. Barreca,et al.  Effects of Extra Training on the Ability of Stroke Survivors to Perform an Independent Sit‐to‐Stand: A Randomized Controlled Trial , 2004 .

[97]  F. Healey,et al.  Using targeted risk factor reduction to prevent falls in older in-patients: a randomised controlled trial. , 2004, Age and ageing.

[98]  Richard H Osborne,et al.  Effectiveness of targeted falls prevention programme in subacute hospital setting: randomised controlled trial , 2004, BMJ : British Medical Journal.

[99]  V. Rosenthal,et al.  Effect of Education and Performance Feedback on Rates of Catheter-Associated Urinary Tract Infection in Intensive Care Units in Argentina , 2004, Infection Control & Hospital Epidemiology.

[100]  J. Fontan,et al.  Medication errors in hospitals: computerized unit dose drug dispensing system versus ward stock distribution system. , 2003, Pharmacy world & science : PWS.

[101]  P. Pronovost,et al.  Medication reconciliation: a practical tool to reduce the risk of medication errors. , 2003, Journal of critical care.

[102]  A. Dromerick,et al.  Relation of postvoid residual to urinary tract infection during stroke rehabilitation. , 2003, Archives of physical medicine and rehabilitation.

[103]  M. Wilde,et al.  A chart audit of factors related to urine flow and urinary tract infection. , 2003, Journal of advanced nursing.

[104]  Kathryn M McDonald,et al.  Changes in rates of autopsy-detected diagnostic errors over time: a systematic review. , 2003, JAMA.

[105]  David M Studdert,et al.  Analysis of errors reported by surgeons at three teaching hospitals. , 2003, Surgery.

[106]  J. Burke,et al.  Infection control - a problem for patient safety. , 2003, The New England journal of medicine.

[107]  E John Orav,et al.  Risk factors for retained instruments and sponges after surgery. , 2003, The New England journal of medicine.

[108]  L. Leape,et al.  Counting deaths due to medical errors [2] (multiple letters) , 2002 .

[109]  R. Hayward Counting deaths due to medical errors. , 2002, JAMA.

[110]  M. Kollef,et al.  The occurrence of ventilator-associated pneumonia in a community hospital: risk factors and clinical outcomes. , 2001, Chest.

[111]  B. Hodgkinson,et al.  Falls risk factors in the hospital setting: a systematic review. , 2001, International journal of nursing practice.

[112]  S. Saint,et al.  Are physicians aware of which of their patients have indwelling urinary catheters? , 2000, The American journal of medicine.

[113]  I. Donald,et al.  Preventing falls on an elderly care rehabilitation ward , 2000, Clinical rehabilitation.

[114]  R. Gibberd,et al.  Epidemiology of medical error , 2000, BMJ : British Medical Journal.

[115]  D. Woods,et al.  Gaps in the continuity of care and progress on patient safety , 2000, BMJ : British Medical Journal.

[116]  T. Brennan,et al.  Incidence and types of adverse events and negligent care in Utah and Colorado. , 2000, Medical care.

[117]  W E Wilkinson,et al.  The Impact of Surgical-Site Infections in the 1990s: Attributable Mortality, Excess Length of Hospitalization, And Extra Costs , 1999, Infection Control & Hospital Epidemiology.

[118]  T. Horan,et al.  Guideline for Prevention of Surgical Site Infection, 1999. Centers for Disease Control and Prevention (CDC) Hospital Infection Control Practices Advisory Committee. , 1999, American journal of infection control.

[119]  Teresa C. Horan,et al.  Guideline for Prevention of Surgical Site Infection, 1999 , 1999, Infection Control & Hospital Epidemiology.

[120]  S. Friedman,et al.  The retained surgical sponge. , 1996, Annals of surgery.

[121]  R Platt,et al.  Serious falls in hospitalized patients: correlates and resource utilization. , 1995, The American journal of medicine.

[122]  N. Laird,et al.  Incidence of Adverse Drug Events and Potential Adverse Drug Events: Implications for Prevention , 1995 .

[123]  Quinlan Wc The liability risk of patients who fall. , 1994 .