Patient Safety/Quality of Care

Analyzing near-miss medical errors by graduate medical trainees can identify ways to improve medical education

In professions such as flying, errors are made in a simulator while pilots are learning to fine-tune their skills. But this is not the case for medical interns and residents—they practice on patients. Lack of supervision, excessive work hours leading to sleep deprivation, and inadequate formal education have been cited as contributing to clinical errors by graduate trainees (GTs).

One way to find the source of GT errors is by analyzing the root causes of both human and system errors as documented in teaching hospital near-miss event reports. Causal trees are used to represent chronologically the critical activities and decisions that led to the event and its recovery, if any. Identifying the cause of errors can guide needed changes to systems and to graduate medical education programs, concludes James B. Battles, Ph.D., a senior service fellow for patient safety at the Agency for Healthcare Research and Quality.

Dr. Battles and his colleague, Christine E. Shea, Ph.D., performed a root-cause analysis of three cases of near-miss medical errors involving GTs (interns, residents, and fellows) that were recorded in hospital-based near-miss reporting systems. In one case, a patient was almost sent home with a fractured cheekbone. The emergency department (ED) was understaffed, and several GTs who were inexperienced in reading x-rays missed the fracture; it was caught by an experienced senior charge nurse. In another case, patients were given inadequate drug treatment for acute asthma in the busy and understaffed ED of a large hospital over a 2-month period during which the staff person responsible for lecturing each new rotation of GTs about asthma medication protocols was out of town.

In both these and the third case, lack of knowledge on the part of the trainee contributed to the incident. In fact, inadequate educational preparation had the potential for significantly harming the patient. Organizational causes also contributed to errors in each case. This illustrates the need to examine not only educational issues, but also procedural and management issues related to graduate medical education, explain the authors. They conclude that near-miss reporting systems can be effective error-management tools.

See "A system of analyzing medical errors to improve GME curricula and programs," by Drs. Battles and Shea, in the February 2001 Academic Medicine 76(2), pp. 125-133.

Reprints (AHRQ Publication No. 01-R045) are available from the AHRQ Publications Clearinghouse.

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