Views of Emergency Medicine Trainees on Adverse Events and Negligence: Survey Results from an Emergency Medicine Training Program in a Regional Health Care System Following the National Standard of Care

Shah HH, Gjelsvik A, Kobayashi L, et al.

Publication Details

Objective: Little is known about the awareness, understanding, and attitudes of emergency medicine (EM) trainees regarding the medicolegal aspects of adverse events statewide. Investigators evaluated EM trainees’ perception of adverse events and medical negligence in Rhode Island. Methods: A cross-sectional questionnaire study was conducted during a randomly selected EM trainee conference. EM trainees rotated in a 966-bed health care system with annual adult and pediatric ED census of over 190,000 patients. Results: Of 28 EM trainees, 17 (61 percent sample; 35 percent target population) participated in the questionnaire assessment. Two-thirds of respondents indicated that health professionals not working together or not communicating as a team were very important causes of adverse events; 12 of 16 respondents properly defined negligence; 5 respondents were able to provide an appropriate example of an adverse event due to negligence. Conclusion: EM trainees are cognizant of adverse events and their causes and perceive medical negligence as a significant problem.

Introduction

Emergency medicine (EM) trainees in the United States strive to treat emergent and nonemergent events in the hospital emergency department (ED) in accordance with established medicolegal care standards.1, 2 Clinical reports3, 4 meticulously document trainees as legally being held to the same standard of care as their attending physicians. Quality of care standards are especially salient when a trainee is faced with a patient adverse event. Yet, in adverse event situations in which care standards do not exist, rules with which to proceed are absent, and a trainee may be at risk for providing negligent care.5 Such situation-specific adverse events, especially in a volatile ED environment where rates of utilization continue to rise, 6 make conditions for EM trainees ever more challenging. Concerns over EM trainee expectations and ED conditions have pressured State and Federal policymakers to formulate streamlined care standards.7, 8

To date, standards of care for physicians and for trainees are inconsistent across the United States. A 2007 commentary by Lewis and colleagues9 noted that 29 States and the District of Columbia are governed by the U.S. national standards, while 21 States are governed by a standard of care based on locality rules. For the former, the United States as the national ruling jurisdiction suggests that general (e.g., internal medicine) and specialty (e.g., emergency medicine) physicians and trainees follow rules typically drafted by professional medical societies. For the latter, with a locality ruling jurisdiction, general and specialty physicians and trainees are held to a State locality rule, in which a statute or case law holds physicians and trainees to the standard of care practiced by those physicians in the “same or similar community” of that State.9 State-to-State variation in patient care standards adds to difficulties facing the medical community when addressing an adverse event due to negligence. In light of practice conditions unique to the specialty, this standard may severely compromise patient safety in EM.10, 11

Little is known about an EM trainee’s awareness of and attitudes about adverse events, negligence, and their relationship to patient safety in the context of a statewide jurisdiction practicing the U.S. national standard of care. As the patient safety topics of adverse events and negligence become drafted into board certification exams,12 surveying of EM trainees—those candidates anticipated to take such tests in the future—might provide general insights and suggest strategies to assess which areas need further attention by EM residency programs and for the betterment of patient safety.

In this study, we assessed views of EM trainees on adverse events with respect to negligence in the State of Rhode Island, where all practicing EM physicians and trainees are expected to follow the U.S. national standard of care, including clinical practice guidelines, position statements, and education resource guides as developed by the Society for Academic Emergency Medicine,13 the American Academy of Emergency Medicine,14 the American College of Emergency Physicians,15 and collaborative partner organizations.

Methods

Study Setting and Population

Forty-eight trainees (12 interns and 36 residents) in the EM residency program affiliated with the Alpert Medical School of Brown University were chosen as the study population. Study participants rotated in three separate EDs of a 966-bed health care system with annual adult and pediatric ED census of over 190,000 patients. Two of these EDs are Level 1 Trauma Centers.

The implementation strategy aimed to capture a representative sample of the study population from an EM residency teaching conference. One conference was randomly selected from those scheduled during 2006. Twenty-eight trainees (58 percent of the target population) were present at the selected meeting. Seventeen of 28 responded to the questionnaire (61 percent sample response rate; 35 percent target population response rate).

Approximately two-thirds of the study sample was male (11/17). A total of 6 interns and 11 residents completed the questionnaire; this represented half (6/12) of the interns and one-third (11/36) of the residents within the target population. Three residents were in their second training year, four residents in their third training year, and four residents in their fourth training year or more of EM. More than half of the respondents (9/17) were within the age range of 25 to 29 years. About one-third of the respondents (6/17) were between the ages of 30 and 34; one respondent was between the ages of 35 and 39. No trainee respondent in this study sample had been sued for malpractice.

Questionnaire Design

This study employed measurement tools from previous studies16, 17, 18, 19, 20 and those developed by the primary investigator (HS). The Institute of Medicine (IOM) definitions of medical error and adverse event were adapted for study use. A medical error was defined as “the failure to complete a planned action as intended or the use of a wrong plan to achieve an aim.” An adverse event was defined as “an injury caused by medical management error rather than the patient’s underlying disease or condition.”16 The latter definition was modified to strictly address medical practice in the United States and to control for training electives abroad.

Examples of adverse events came from a previous study17 addressing views of residents on medical error and adverse events causes: “pneumothorax, retained objects, hospital-acquired infections, decubitus ulcers, perioperative myocardial infarctions (MIs), line infections, and falls.” Finally, the American Board of Medical Specialties – Council of Medical Specialty Societies (ABMS-CMSS) semantic and literature review helped develop a uniform definition of negligence as: “Medical care that fell short of the expected standards; expected standards refer to widespread use by U.S. EM physicians, and/or national or local organization-based written guidelines in the contextual situation.”12, 18

Twelve main questions, divided into four sections, were included in the questionnaire. Sections were developed and ordered based on a review of patient safety literature. Quantitative questions included: “General Issues of Adverse Events,” “Causes of Adverse Events,” “Strategies to Reduce Adverse Events,” and “Malpractice Issues.” The “General Issues of Adverse Events” section, with six questions [Q1 – Q6] derived from a previous national study,19 was designed to introduce the terminology of adverse events and engage the respondent to think of adverse events. The standardized questionnaire was pretested on an internal medicine residency program at the same institution and modified for content validity. Full description and study results are in an unpublished report.21

The “Causes of Adverse Events” section, with one question [Q7], aimed to transition to the topic of adverse events by querying subjects on objectively identified causes of hospital-based adverse events. The “Strategies to Reduce Adverse Events” section, with one question [Q8], asked respondents to consider several national strategies proposed by physician experts to reduce adverse events. The “Malpractice Issues” section, with two open-ended questions [Q9–Q10] and two closed-ended questions [Q11–Q12], was designed to evaluate views on the medico-legal aspects of EM practice and personal experience, respectively. One question [Q11] of malpractice fear came from a previous report20 using skilled opinion and factor analysis. (This main section was addressed last, as malpractice can be a sensitive topic and might be perceived as intrusive.22) Finally, six questions [Q13 – Q18], asked for trainee demographic information.23 The EM Trainee Patient Safety Questionnaire can be found in the Appendix.

Implementation Strategy

This study utilized a cross-sectional design and was conducted during an EM trainee conference. The purpose of the study and the importance of confidentiality were explained to the trainees. A typewritten questionnaire instrument and blank envelope were distributed to each trainee present at the conference. Trainees were asked to read the written consent form and instructions section, serving as the first page of the questionnaire instrument, and to complete it privately on a voluntary basis.24 No honorarium was offered. Trainees placed their completed questionnaires in anonymous envelopes that were then collected in a separate container. The Institutional Review Board at the participating health care system approved the study.

Questionnaire Analysis

All categorical data from the questionnaire instruments were entered into Epi Info™ version 3.3.2, and free-text answers were transcribed verbatim. Data entry was rechecked for quality purposes. Categorical results were analyzed by cross-tabulation.

Open-ended responses were qualitatively assessed for thematic content; 25 answers that fell into a specific theme were tabulated. Those answers that did not fall into a theme were tabulated into a section entitled “other.” Response meanings of adverse events were analyzed by reviewing statements that addressed the theme of “care that fell short of the expected standard” or any variations of those words (e.g., providing substandard care); these were tabulated into two columns, either noted directly or indirectly. Statements addressing negligence as doing harm to a patient were added into a separate column. Response examples of adverse events due to negligence were qualitatively analyzed by separating each content description into three areas: context, standard of care, and injury. Each standard-of-care response was then considered in context and compared with written guideline policies15 (when available) in widespread use by EM physicians as the U.S. national standard of care. An EM physician analyzed the results for depth and validity. Full responses from the open-ended questions are detailed in the Results section. For the purpose of improved clarity, acronym and grammatical errors have been corrected without changing the phrase content or meaning.

Results

Closed-Ended Categorical Analysis

General issues of adverse events. All respondents (17/17) labeled adverse events as a problem that is at least “important.” More than half the respondents (10/17) marked adverse events as occurring at least “often.” Less than half the respondents (8/17) considered the patient partially responsible for adverse events made during their care. Three-fourths of the respondents (12/16) agreed on keeping hospital reports of adverse events confidential instead of releasing them to the public; one of the respondents did not appropriately check the item, so this was omitted from the analysis. All respondents except one (16/17) agreed that physicians should be required to inform patients about an adverse event that resulted in serious harm. All but two respondents (15/17) marked the most important cause of adverse events as mistakes made by physicians; the remaining two marked two important causes (the question explicitly stated to choose only one answer): accordingly, their responses were omitted from the analysis.

Causes of adverse events. Among the four listed causes of adverse events, almost two-thirds of the respondents (11/17) marked health professionals not working together or not communicating as a team to be “very important” causes. Next, overwork, stress, or fatigue was marked as a “very important” cause of adverse events by less than half the respondents (7/17). Not having enough nurses and poor supervision of health care professionals were labeled as “somewhat important” causes of adverse events by two-thirds of the respondents (12/17 and 11/17, respectively).

Strategies for reducing adverse events. From four listed strategies for reducing adverse events, more than three-quarters of the respondents (13/17) marked the use of an online adverse event reporting system as at least “somewhat effective.” Providing a mechanism of coping support was marked by more than two-thirds of respondents (12/17) as at least “somewhat effective.” Having adverse events addressed in board certification exams was marked by more than half the respondents (10/17) as at least “somewhat effective.” However, one listed item was overwhelmingly perceived as a noneffective solution: three-quarters of the respondents (13/17) considered the development of a system to quickly and fairly compensate an injured patient as at least “not effective.”

Malpractice issues. Of the six listed items of malpractice concern, more than half the respondents (9/17) “strongly agreed” on the statement regarding the use of clinical judgment rather than technology to make decisions as a risky endeavor. The feeling of pressure from a day-to-day threat of malpractice litigation, as well as the ordering of tests/consultations to avoid the appearance of malpractice, were noted with “strong agreement” by more than half the respondents (9/17 and 9/17, respectively). Less than half the respondents (7/17) “strongly agreed” on asking for consultant opinions to reduce the risk of being sued. The concern of being involved in a malpractice case sometime in the next 10 years was “strongly agreed” upon by less than half the respondents (6/17) compared with the previous four items. Finally, the issue of having to make significant changes in practice patterns because of recent legal developments was decisively not “strongly agreed” upon by respondents (3/17). Results of all closed-ended responses are documented in Table 1.

Table 1. EM trainee closed-ended responses [Q1-8; Q11-17] & open-ended responses [Q18] (%).

Table 1

EM trainee closed-ended responses [Q1-8; Q11-17] & open-ended responses [Q18] (%).

Open-Ended Qualitative Analysis

Meaning of negligence. Responses to an open-ended query to assess how trainees defined negligence were qualitatively assessed for thematic content, based on the U.S. national standard of care definition. Three-quarters of the responses (12/16) directly or indirectly addressed the theme of substandard care. Select responses included: (a) “Failure to provide care equal to the standard of care in terms of thoroughness, timeliness”; (b) “Intentional lack of the appropriate attention to patient care or management, resulting in patient harm; not abiding by practice patterns considered to be the standard of care”; and (c) “Not providing the standard of care.” Some responses that addressed negligence other than substandard care included: (a) “Doing harm without consideration of alternative medical therapies or inattention to procedure/clinical management”; (b) “Willful action that causes damage”; and (c) “Not being aware of a medical problem or failing to search for it.” Table 2 contains all 16 responses.

Table 2. EM trainee open-ended responses [Q9] to the meaning of negligence.

Table 2

EM trainee open-ended responses [Q9] to the meaning of negligence.

Examples of adverse events due to negligence. Based on sample responses, three themes were developed: (1) a theme addressing both components of adverse events and negligence (5 examples); (2) a theme addressing negligence, but no adverse event injury (11 examples); and (3) a theme for responses with inadequate information or context for reliable assessment (12 examples). All 28 responses are provided in Table 3.

Table 3. EM trainee open-ended responses [Q10a&b] to examples of adverse events due to negligence.

Table 3

EM trainee open-ended responses [Q10a&b] to examples of adverse events due to negligence.

Statements addressing an adverse event due to negligence made up less than one-fifth of the responses (5/28). Some examples noted: (a) “Placing central line quickly without consideration for ultrasound guided peripheral line, and sustaining a complication”; (b) “Giving patient pneumothorax post-central venous access placement and not checking chest x-ray”; and (c) “Patient who dies after ruptured ectopic 2 days after coming to hospital with abdomen pain and sent/brought home without a urine pregnancy test.”

Statements addressing a negligence-based event made up less than half the responses (11/28). Some examples were: (a) “1-month old presents with fever, lethargy, no workup despite two presentations”; (b) “Intubating the esophagus and not recognizing it”; and (c) “Not giving antibiotics within 4 hours of a pneumonia presenting to the emergency room.”

Finally, statements addressing no clear theme made up 40 percent of the responses (12/28). Some examples included: (a) “Not calling cardiology for an ST-elevation myocardial infarction”; (b) “Failure to obtain a post-central line chest x-ray”; and (c) “Not ordering an appropriate test.”

Discussion

Overview

This statewide assessment found that EM trainees understood the importance of studying adverse events. The study also found that EM trainees were concerned with medical negligence. Previous ED work26 has addressed EM trainee views on patient safety issues, but it did not clarify whether trainees practiced in a jurisdiction that followed the U.S. national standards of care or the locality rule. The jurisdiction in our study was defined to help create a more precise context for assessing patient safety issues associated with adverse events and negligence.

In our study, EM trainee respondents viewed adverse events as an important issue of clinical practice. This compares with another study17 assessing trainee views on adverse events in a different State. As frontline physicians, trainees are a target population that encounters many situation-specific events. Accordingly, the emotional and affective drive to improve patient care may be high within this population.

We found an overwhelming majority of the respondents (75 percent of 16 EM trainees) preferred that adverse event reporting be kept confidential and used only as a deterrent to future errors. This finding parallels the 2002 project, “U.S. Medical Error: Practicing Physicians and Public Views Study.”19 In that study, a representative sample of 831 U.S. physicians was assessed via mail and online survey; the majority (86 percent) of respondents chose the same option. Confidentiality of adverse event reports and their use as a feedback mechanism might be appropriate to improve EM trainee curricula on preventability vs. nonpreventability of adverse events. Incorporating confidential reporting systems may be suitable for EM residency trainee programs seeking to develop or enhance preexisting adverse event learning programs via improving dialogue about adverse events among trainees and other health care providers. 27

Emergency medicine trainee respondents also marked health professionals’ overwork, stress, fatigue, and the inability to communicate as a team as important factors contributing to preventable adverse events that lead to serious patient harm. The “U.S. Medical Error Study”19 assessed this aspect and found that 50 percent of practicing physicians nationwide viewed these factors as barriers to improving patient safety. Our study specifically studied the term “adverse event.” Accordingly, it may be that frontline EM trainees find stress and communication failures perpetuate preventable adverse events. Mechanisms that improve communication through teamwork approaches for the reduction of bedside errors and that reduce EM trainee stress need to be further investigated.

As an effective strategy to deter adverse events that result in serious harm, EM trainee respondents emphasized coping support for health professionals. Other medical specialties have used focus groups and surveys to assess trainee views on coping methods. A focus-group study28 of the impact of stress on British surgery trainees found strategies to overcome stress-based adverse outcomes. These strategies included “stop and stand back,” distancing technique, and self-talk. A survey study29 of emotionally burnt-out U.S. internal medicine trainees found that, when they used discussion strategies to talk about trainee errors with clinical colleagues, family, and friends, it was beneficial. Coping strategies for EM trainees merit attention as demands of cognition and decisionmaking are substantial within the ED—i.e., a high degree of uncertainty, undifferentiated problems of varying acuity, and a need for expeditious intervention.30, 31

EM trainee respondents overwhelmingly reported that the development of a system that quickly and fairly compensates a patient injured by an adverse event as noneffective. Methods to make restitution for patients who have experienced medical injury warrant further discussion. The lack of studies addressing litigation and EM practice is serious, as the number of claims filed against EM trainees, especially for diagnostic errors, is moderate to high.32 Future studies should investigate other avenues to address this issue in the ED arena.

Most EM trainee residents noted the following concerns as weighing against their work: the threat of malpractice litigation, the ordering of more tests to avoid the appearance of little testing (an assurance offensive tactic),33 and the risk of clinical judgment. The risk of clinical judgment was a high concern in another study20 that surveyed EM physicians, rather than EM trainees, in university-affiliated hospitals. In that study, EM physicians were grouped based on their risk-taking behaviors of lower, middle, and upper. Interestingly, all groups strongly agreed that relying on clinical judgment rather than on technology to make a diagnosis is becoming riskier. This similarity may stem from the nature of EM work in a volatile malpractice environment. That study, though, did not specify the target population’s patient care standards; a comparison with incomplete context may lead to a conjecture. Specifying region- and State-based ruling jurisdictions may help future work improve the assessment of EM trainees and physicians concerns.

Rather than asking negligence-related questions based on vignettes, as has been done in previous empirical work, 33, 34 in this study we asked open-ended questions to define negligence and provide examples of an adverse event due to negligence. Almost all of the EM trainee respondents were able to define negligence from a U.S. national standard of care viewpoint. However, respondents had difficulty providing examples of adverse events due to negligence. Most respondents provided examples of negligence but not negligence-based adverse events.

In those examples that correctly provided an adverse event due to negligence, the substandard component was incorrect diagnostic testing or inadequate assessment.

This result signaled that some EM trainees practicing under the U.S. national standard of care might be cognizant of missed diagnoses and inadequate assessments while making decisions. Missed and delayed diagnoses tend to be situation-specific events. Accordingly, when EM trainees are confronted with this in the absence of rules, they might be uncertain as to how to proceed. It is important, therefore, that the EM trainee remains under the supervision of an attending physician whenever such situations arise.3 Educational interventions and instructional exercises could further aid EM trainees in appropriate responses to adverse events due to negligence in situation-specific events.

Overall, the results from our study underscore practical ways to assess EM trainees’ awareness of and attitudes about adverse events with respect to negligence in a State practicing the national standard of care. Published literature35, 36, 37 finds many pervasive barriers to adverse event research, especially due to the complexity of medicolegal rules across States and relative to the U.S. health care system. In the volatile ED setting, reporting may be further complicated by situation-specific events. Consequently, the EM specialty must consider this when planning interventions and board exams to improve patient safety. 38, 39

Limitations

Results from this study may not be generalizable to other States that might operate under a different standard of care. Additionally, we were unable to capture information on each trainee’s ability to tolerate risk and uncertainty (e.g., risk-seeking vs. risk-avoiding personalities40). The small sample size precluded an ability to conduct statistical significance analyses among the demographic variables and each of the four main theme-based questions. The questionnaire used examples of adverse event injuries, but it did not consider threshold levels. For instance, past large-scale epidemiologic work41, 42 has categorized adverse event outcomes into severity scale injury levels. Finally, the developed questionnaire was erroneously printed with a hospital (Memorial) where rotations did not occur. However, no respondents checked the “other” option to indicate rotation-based hospital work at area hospitals. Therefore, the error is presumed to have had a trivial effect on the validity of participants’ responses.

Conclusion

This study assessed EM trainees’ understanding and perceptions of adverse events and negligence in the State of Rhode Island, where practicing physicians and trainees abide by the U.S. national standard of care. The physicians in training who were surveyed were cognizant of medical negligence and significantly concerned about its impact on clinical practice.

Acknowledgments

This study was supported by the Views of Non-Clinicians and Clinicians on Hospital Patient Safety: Results from Descriptive Interviews and Questionnaires Implemented in Rhode Island Project. Parts of this work were presented in poster and oral format at the Society for Academic Emergency Medicine, New England Regional Research Conference, April 18, 2007, Shrewsbury, MA; and at the America’s Social Contract – Roosevelt Institute/Yale University Conference, April 27, 2007, New Haven, CT, respectively. We thank the anonymous referees for their insightful comments.

Appendix. EM Trainee Patient Safety Questionnaire

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References

1.
Sox CM, Burstin HR, Orav EJ, et al. The effect of supervision of residents on quality of care in five university-affiliated emergency departments. Acad Med. 1998;73:776–782. [PubMed: 9679467]
2.
Berger E. Breaking point: Report calls for congressional rescue of hospital emergency departments. Ann Emerg Med. 2006;48:140–142. [PubMed: 16953525]
3.
Kachalia A, Studdert DM. Professional liability issues in graduate medical education. JAMA. 2004;292:1051–1056. [PubMed: 15339896]
4.
Ott CJ, Houry DE. Medical malpractice and the emergency medicine resident. Ann Emerg Med. 2000;36:631–633. [PubMed: 11097709]
5.
Empey M, Carpenter C, Jain P. What constitutes the standard of care? Ann Emerg Med. 2004;44:527–531. [PubMed: 15520714]
6.
Nawar EW, Niska RW, Xu J, et al. National Hospital Ambulatory Medical Care Survey: 2005 emergency department summary site. Advance data from vital and health statistics, No. 386. 2007. [Accessed March 23, 2008]. Available at: www​.cdc.gov/nchs/data/ad/ad386.pdf. [PubMed: 17703794]
7.
Vincent C, Simon R, Sutcliffe K, et al. Errors conference: Executive summary. Acad Emerg Med. 2000;7:1180–1182. [PubMed: 11073464]
8.
Kennedy TJT, Lingard L, Baker GR, et al. Clinical oversight: Conceptualizing the relationship between supervision and safety. J Gen Int Med. 2007;22:1080–1085. [PMC free article: PMC2305735] [PubMed: 17557190]
9.
Lewis MH, Gohagan JK, Merenstein DJ. The locality rule and the physician’s dilemma: Local medical practices vs the national standard of care. JAMA. 2007;297:2633–2637. [PubMed: 17579232]
10.
Samanta A, Mello MM, Foster C, et al. The role of clinical guidelines in medical negligence litigation: A shift from the Bolam Standard? Med Law Rev. 2006;14:321–366. [PubMed: 16901977]
11.
Mello MM. Of swords and shields: The use of clinical practice guidelines in medical malpractice litigation. Univ Penn Law Rev. 2001;149:645–710.
12.
Kachalia A, Johnson JK, Miller S, et al. The incorporation of patient safety into board certification examinations. Acad Med. 2006;81:317–325. [PubMed: 16565180]
13.
Education resources. Lansing, MI: Society for Academic Emergency Medicine; 2008. [Accessed March 23, 2008]. Available at: www​.saem.org/saemdnn​/Home/Education/EducationResources​/tabid/57/Default.aspx.
14.
Position Statements. Milwaukee, WI: American Academy of Emergency Medicine; 2007. [Accessed March 23, 2008]. Available at: www​.aaem.org/positionstatements/
15.
Risk management outline and resources for educators. Irving, TX: American College for Emergency Physicians; 2004. Available at: www​.acep.org/WorkArea/downloadasset​.aspx?id=5882. March 23, 2008.
16.
Kohn KT, Corrigan JM, Donaldson MS, editors. To err is human: Building a safer health system. Washington, DC: National Academies Press; 2001.
17.
Jagsi R, Kitch BT, Weinstein DF, et al. Residents report on adverse events and their causes. Arch Int Med. 2005;165:2607–2713. [PubMed: 16344418]
18.
Brennan TA. The Institute of Medicine report on medical errors – Could it do harm? N Eng J Med. 2000;342:1123–1125. [PubMed: 10760315]
19.
Blendon RJ, DesRoches CM, Brodie M, et al. Views of practicing physicians and the public on medical errors. N Eng J Med. 2002;347:1933–1940. [PubMed: 12477944]
20.
Katz DA, Williams GC, Brown RL, et al. Emergency physicians’ fear of malpractice in evaluating ischemic patients with possible acute cardiac ischemia. Ann Emerg Med. 2005;46:525–533. [PubMed: 16308068]
21.
Shah HH. Patient safety questionnaire assessment. Views of postgraduate year 2 (PGY2) general internal medicine residents training at a Rhode Island Hospital on preventable medical errors (unpublished data) 2006 May 8
22.
Studdert DM, Mello MM, Brennan TA. Medical malpractice. N Eng J Med. 2004;350:283–292. [PubMed: 14724310]
23.
Fowler FJ. Improving survey questions: Design and evaluation. Thousand Oaks, CA: Sage; 1995.
24.
Groves RM, Fowler FJ, Couper MP, et al. Survey methodology. Hoboken, NJ: John Wiley & Sons, Inc; 2004.
25.
Ritchie J, Spencer L. Qualitative data analysis for applied policy research. In: Bryman A, Burgess R, editors. Analysing qualitative data. London: Routledge; 1994.
26.
Hobgood C, Hevia A, Tamayo-Sarver JH, et al. The influences of the causes and contexts of medical errors on emergency medicine residents’ responses to their errors: An exploration. Acad Med. 2005;80:758–764. [PubMed: 16043533]
27.
Weingart SM, Callanan LN, Ship AN, et al. A physician-based voluntary reporting system for adverse events and medical errors. J Gen Int Med. 2001;16:809–814. [PMC free article: PMC1495298] [PubMed: 11903759]
28.
Wetzel CM, Kneebone RL, Woloshynowych M, et al. The effects of stress on surgical performance. Am J Surg. 2006;191:5–10. [PubMed: 16399098]
29.
West CP, Huschka MM, Novotny PJ, et al. Association of perceived medical errors with resident distress and empathy. JAMA. 2006;296:1071–1078. [PubMed: 16954486]
30.
Croskerry P, Sinclair D. Emergency medicine: A practice prone to error? Can J Emerg Med. 2001;3:271–276. [PubMed: 17610769]
31.
Widger HN, Moffat JC. Standards of care in emergency medicine: A practical guide to emergency procedures and legal liability. Boston: Wolters Kluwer Law & Business; 2007.
32.
Kachalia A, Gandhi TK, Puopolo 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. [PubMed: 16997424]
33.
Studdert DM, Mello MM, Sage WM. Defensive medicine among high-risk specialist physicians in a volatile malpractice environment. JAMA. 2005;293:2609–2617. [PubMed: 15928282]
34.
Defensive medicine and medical practice. Washington, DC: Office of Technology Assessment, US Congress; 1994. Publication OTA-H-602.
35.
Rodriguez RM, Anglin D, Hankin A, et al. A longitudinal study of emergency medicine residents’ malpractice fear and defensive medicine. Acad Emerg Med. 2007;14:569–573. [PubMed: 17446194]
36.
Stanhope N, Crowley-Murphy M, Vincent C, et al. An evaluation of adverse incident reporting. J Eval Clin Pract. 1999;5:5–12. [PubMed: 10468379]
37.
Vincent C, Stanhope N, Crowley-Murphy M. Reasons for not reporting adverse incidents: An empirical study. J Eval Clin Pract. 1999;5:13–21. [PubMed: 10468380]
38.
Lawton R, Parker D. Barriers to incident reporting in a healthcare system. Qual Saf Health Care. 2002;11:15–18. [PMC free article: PMC1743585] [PubMed: 12078362]
39.
Hobgood C, Weiner B, Tamayo-Sarver JH, et al. Medical error identification, disclosure, and reporting: Do emergency medicine provider groups differ? Acad Emerg Med. 2006;13:443–451. [PubMed: 16531598]
40.
Schenkel S. Promoting patient safety and preventing medical error in emergency departments. Acad Emerg Med. 2000;7:1204–1222. [PubMed: 11073469]
41.
Katz DA, Williams GC, Brown RL, et al. Emergency physicians’ fear of malpractice in evaluating ischemic patients with possible acute cardiac ischemia. Ann Emerg Med. 2005;46:525–533. [PubMed: 16308068]
42.
Weiler PC, Hiatt HH, Newhouse JP, et al. A measure of malpractice. Cambridge, MA: Harvard University Press; 1993.