Display Settings:

Format

Send to:

Choose Destination
See comment in PubMed Commons below
Eff Clin Pract. 2000 Nov-Dec;3(6):261-9.

What is an error?

Author information

  • 1Department of Veterans Affairs, VA Center for Practice Management and Outcomes Research, VA Ann Arbor Healthcare System, Ann Arbor, Mich., USA. thofer@umich.edu

Abstract

CONTEXT:

Launched by the Institute of Medicine's report, "To Err is Human," the reduction of medical errors has become a top agenda item for virtually every part of the U.S. health care system.

OBJECTIVE:

To identify existing definitions of error, to determine the major issues in measuring errors, and to present recommendations for how best to proceed.

DATA SOURCE:

Medical literature on errors as well as the sociology and industrial psychology literature cited therein.

RESULTS:

We have four principal observations. First, errors have been defined in terms of failed processes without any link to subsequent harm. Second, only a few studies have actually measured errors, and these have not described the reliability of the measurement. Third, no studies directly examine the relationship between errors and adverse events. Fourth, the value of pursuing latent system errors (a concept pertaining to small, often trivial structure and process problems that interact in complex ways to produce catastrophe) using case studies or root cause analysis has not been demonstrated in either the medical or nonmedical literature.

CONCLUSION:

Medical error should be defined in terms of failed processes that are clearly linked to adverse outcomes. Efforts to reduce errors should be proportional to their impact on outcomes (preventable morbidity, mortality, and patient satisfaction) and the cost of preventing them. The error and the quality movements are analogous and require the same rigorous epidemiologic approach to establish which relationships are causal.

Comment in

  • On errors. [Eff Clin Pract. 2001]
  • On errors. [Eff Clin Pract. 2001]
PMID:
11151522
[PubMed - indexed for MEDLINE]
Free full text
PubMed Commons home

PubMed Commons

0 comments
How to join PubMed Commons

    Supplemental Content

    Full text links

    Icon for American College of Physicians-American Society of Internal Medicine
    Loading ...
    Write to the Help Desk