Dataset Information

Sins of omission: getting too little medical care may be the greatest threat to patient safety.

ABSTRACT:

Background

Little is known about the relative incidence of serious errors of omission versus errors of commission.

Objective

To identify the most common substantive medical errors identified by medical record review.

Design

Retrospective cohort study.

Setting

Twelve Veterans Affairs health care systems in 2 regions.

Participants

Stratified random sample of 621 patients receiving care over a 2-year period.

Main outcome measure

Classification of reported quality problems.

Methods

Trained physicians reviewed the full inpatient and outpatient record and described quality problems, which were then classified as errors of omission versus commission.

Results

Eighty-two percent of patients had at least 1 error reported over a 13-month period. The average number of errors reported per case was 4.7 (95% confidence intervals [CI]: 4.4, 5.0). Overall, 95.7% (95% CI: 94.9%, 96.4%) of errors were identified as being problems with underuse. Inadequate care for people with chronic illnesses was particularly common. Among errors of omission, obtaining insufficient information from histories and physicals (25.3%), inadequacies in diagnostic testing (33.9%), and patients not receiving needed medications (20.7%) were all common. Out of the 2,917 errors identified, only 27 were rated as being highly serious, and 26 (96%) of these were errors of omission.

Conclusions

While preventing iatrogenic injury resulting from medical errors is a critically important part of quality improvement, we found that the overwhelming majority of substantive medical errors identifiable from the medical record were related to people getting too little medical care, especially for those with chronic medical conditions.

SUBMITTER: Hayward RA

PROVIDER: S-EPMC1490182 | biostudies-literature | 2005 Aug

REPOSITORIES: biostudies-literature

ACCESS DATA

Publications

Sins of omission: getting too little medical care may be the greatest threat to patient safety.

Hayward Rodney A RA Asch Steven M SM Hogan Mary M MM Hofer Timothy P TP Kerr Eve A EA

Journal of general internal medicine 20050801 8

<h4>Background</h4>Little is known about the relative incidence of serious errors of omission versus errors of commission.<h4>Objective</h4>To identify the most common substantive medical errors identified by medical record review.<h4>Design</h4>Retrospective cohort study.<h4>Setting</h4>Twelve Veterans Affairs health care systems in 2 regions.<h4>Participants</h4>Stratified random sample of 621 patients receiving care over a 2-year period.<h4>Main outcome measure</h4>Classification of reported ...[more]

PMID: 16050875

Similar Datasets

Project description:ObjectiveTo identify lessons learned from the experience of the Agency for Healthcare Research and Quality (AHRQ) Patient Safety and Medical Liability (PSML) Demonstration Program.Data sources/study settingOn September 9, 2009, President Obama directed the Secretary of Health and Human Services to authorize demonstration projects that put "patient safety first" with the intent of reducing preventable adverse outcomes and stemming liability costs. Seven demonstration projects received 3 years of funding from AHRQ in the summer of 2010, and the program formally came to a close in June 2015.Study designThe seven grantees implemented complex, broad-ranging innovations addressing both patient safety and medical liability in "real-world" contexts. Some projects featured novel approaches, while others implemented adaptations of existing models. Each project was funded by AHRQ to collect data on the impact of its interventions. In addition, AHRQ funded a cross-cutting qualitative evaluation focused on lessons learned in implementing PSML interventions.Data collection/extraction methodsSite visits and follow-up interviews supplemented with material abstracted from formal project reports to AHRQ.Principal findingsThe PSML demonstration projects focused on three broad approaches: (1) improving communication around adverse events through disclosure and resolution programs; (2) preventing harm through implementation of clinical "best practices"; and (3) exploring alternative methods of settling claims. Although the demonstration contributed to accumulating evidence that these kinds of interventions can positively affect outcomes, there is also evidence to suggest that these interventions can be difficult to scale.ConclusionsIn addition to producing at least preliminary positive outcomes, the demonstration also lends credence to the idea that targeted interventions that improve some aspect of patient safety or malpractice performance may also contribute more broadly to institutional culture and the alignment of all parties around reducing risk and preventing harm. However, more empirical work needs to be carried out to quantify the effect of such interventions.

Dataset Information

Sins of omission: getting too little medical care may be the greatest threat to patient safety.

Background

Objective

Design

Setting

Participants

Main outcome measure

Methods

Results

Conclusions

Publications

Sins of omission: getting too little medical care may be the greatest threat to patient safety.

Similar Datasets

OmicsDI is part of the ELIXIR infrastructure

Tweets