publicdata/ahrq-gov
1
0
Fork 0
Code Issues Pull requests Projects Releases Packages Wiki Activity Actions
ahrq-gov/archive.ahrq.gov/research/mar08/0308RA3.htm
Scott Williams 58222b51ed Initial commit
2025-02-28 14:14:25 -05:00

155 lines
No EOL
14 KiB
HTML
Raw Blame History

<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Transitional//EN"
"http://www.w3.org/TR/xhtml1/DTD/xhtml1-transitional.dtd">
<html xmlns="http://www.w3.org/1999/xhtml">
<head>
<title>Research Activities, March 2008: Patient Safety and Quality: Studies reveal factors contributing to technical errors in surgery and medical errors made by physician trainees</title>
<meta http-equiv="Content-Type" content="text/html; charset=iso-8859-1" />
<!-- "metadata" -->
<meta name="Title" content="Research Activities, March 2008" />
<meta name="keywords" content="Agency for Health Care Policy and Research, Agency for Healthcare Research and Quality, AHRQ, AHCPR, AIDS/HIV, ambulatory care, benchmark, child, cost, elderly, health cost, healthcare cost, hospital, long-term care, managed care, markets, mental health, methodology, minority health, nursing, nursing homes, outcome research, out-of-pocket spending, patient care, primary, primary care, research, rural, spending, study, Translating Research Into Practice, TRIP" />
<meta name="description" content="March 2008 issue of online newsletter summarizing published findings from AHRQ-funded studies, new AHRQ publications and products, and funding opportunities." />
<meta name="datecreated" content="March 2008" />
<meta name="datereviewed" content="March 2008" />
<meta name="language" content="English" />
<!-- end metadata -->
<link href="/includes/archive.css" rel="stylesheet" type="text/css" />
<link href="/includes/ahrqstyleprint_arch.css" rel="stylesheet" type="text/css" media="print" />
<script>
(function(i,s,o,g,r,a,m){i['GoogleAnalyticsObject']=r;i[r]=i[r]||function(){
(i[r].q=i[r].q||[]).push(arguments)},i[r].l=1*new Date();a=s.createElement(o),
m=s.getElementsByTagName(o)[0];a.async=1;a.src=g;m.parentNode.insertBefore(a,m)
})(window,document,'script','//www.google-analytics.com/analytics.js','ga');
ga('create', 'UA-75759936-1', 'auto');
ga(' set', 'anonymizeIp', true);
ga('send', 'pageview');
</script></head>
<body><!-- Google Tag Manager -->
<noscript><iframe src="//www.googletagmanager.com/ns.html?id=GTM-W4DST4"
height="0" width="0" style="display:none;visibility:hidden"></iframe></noscript>
<script>(function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':
new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],
j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src=
'//www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);
})(window,document,'script','dataLayer','GTM-W4DST4');</script>
<!-- End Google Tag Manager -->
<noscript>
Your browser doesn't support JavaScript. Please upgrade to a modern browser or enable JavaScript in your existing browser.
</noscript>
<!-- Page Header v2.0 -->
<a name="top" id="top"></a>
<!--Begin Banner CodeS-->
<div id="ahrqbanner">
<div class="hhsportion">
<a href="#h1" class="skipnav">Skip Navigation</a>
<a href="http://www.hhs.gov" title="U.S. Department of Health and Human Services">
<img src="/images/hhs_banner.gif" alt="U.S. Department of Health and Human Services" />
</a>
<a href="http://www.hhs.gov" title="www.hhs.gov" class="hhsright">
<img src="/images/hhs_link.gif" alt="www.hhs.gov" />
</a>
</div>
<div class="ahrqportion">
<a href="/" title="Archive: Agency for Healthcare Research Quality">
<img src="/images/ahrq_banner.gif" alt="Agency for Healthcare Research Quality" />
</a><form name="searchForm" method="get" action="https://search.ahrq.gov/search" id="banner_searchform">
<label for="search" style="z-index:-1;position:relative;margin-right:-65px; font-size:0px;">Search</label>
<input name="q" type="text" value=" Search Archive" size="11" onfocus="this.value='';" class="gotext" label="Search archive" id="search" />
<input type="hidden" name="entqr" value="0" />
<input type="hidden" name="output" value="xml_no_dtd" />
<input type="hidden" name="proxystylesheet" value="ARCHIVE_Front_End" />
<input type="hidden" name="client" value="ARCHIVE_Front_End" />
<input type="hidden" name="site" value="ARCHIVE_AHRQ_GOV" />
<input src="/images/topbn_GoButton.gif" class="gobtn" name="Submit" onclick="javascript:document.searchForm.submit();" type="image" alt="Search" />
</form>
<a href="https://www.ahrq.gov/" class="ahrqright">www.ahrq.gov</a>
</div><div class="ahrqlinks"><a href="https://www.ahrq.gov/">AHRQ Home&#8212;Live Site</a> | <a href="/">Archive Home</a> | <a href="/sitemap.htm">Site Map</a> <!-- | &nbsp;<img src="/images/envelope1.jpg" alt="" width="21" height="14" /><a href="https://subscriptions.ahrq.gov/service/multi_subscribe.html?code=USAHRQ">E-mail Updates</a> --></div>
</div>
<div id="PrintBanner">
<img src="/images/printbanner_arch.jpg" alt="Archive print banner" />
</div>
<a name="h1"></a>
<!-- End banner code -->
<!-- End of Page header -->
<!-- Content Body -->
<div id="mainContent">
<table width="100%" border="0" cellspacing="0" cellpadding="0" >
<tr valign="top">
<td width="70%">
<!-- Center Content section -->
<table width="100%" border="0" cellpadding="0" cellspacing="0" style="margin-left:10px; margin-right:10px;margin-top:5px" summary="This table gives the layout format of the bread crumb area and the center content area.">
<!--DWLayoutTable-->
<tr>
<td class="crumb_link"><div id="crumbContent">
<p><strong>You Are Here:</strong> <span class="crumb_link"><a href="/" class="crumb_link">AHRQ Archive Home</a> &gt; <a href="/research/resarch.htm" class="crumb_link"><em>Research Activities</em> Archive</a> &gt; <a href="." class="crumb_link">March 2008</a> </span></p>
</div>
</td>
</tr>
<tr>
<td><h1><a name="h1" id="h1"></a>Patient Safety and Quality</h1>
</td>
</tr>
<tr>
<td><div id="centerContent"><div class="headnote">
<p>This information is for reference purposes only. It was current when produced and may now be outdated. Archive material is no longer maintained, and some links may not work. Persons with disabilities having difficulty accessing this information should contact us at: <a href="https://info.ahrq.gov/">https://info.ahrq.gov</a>. Let us know the nature of the problem, the Web address of what you want, and your contact information. </p>
<p>Please go to <a href="https://www.ahrq.gov/">www.ahrq.gov</a> for current information.</p></div>
<h2>Studies reveal factors contributing to technical errors in surgery and medical errors made by physician trainees</h2>
<p>The majority of technical errors in surgery are made by experienced surgeons during routine operations on complex patients and/or in complex circumstances. In contrast, errors in judgment, teamwork breakdowns, and lack of technical competence contribute most to the medical errors that physician trainees make. Those are the conclusions of two studies that reviewed malpractice claims from several liability insurers. The studies were supported by the Agency for Healthcare Research and Quality (HS11886, HS11285, HS11544, and T32 HS00020), and are briefly described here.</p>
<p><strong>Regenbogen, S.E., Greenberg, C.C., Studdert, D.M., and others (2007, November). "Patterns of technical errors among surgical malpractice claims: An analysis of strategies to prevent injury to surgical patients." <em>Annals of Surgery</em> 246(5), pp. 705-711.</strong><br /><br />
Most technical errors in surgery (73 percent), such as nicking the bladder during a hysterectomy, are made by experienced surgeons during routine operations (84 percent) on complex patients and/or in complex circumstances. A review of 444 malpractice claims from 4 liability insurers revealed that 258 involved injuries due to surgical errors, and technical errors were a contributing factor in 52 percent of the cases. Nearly half (49 percent) of the technical errors caused permanent disability and an additional 16 percent resulted in death. Two-thirds (65 percent) of the technical errors were linked to manual errors (errors of execution with a direct physical act causing injury), 9 percent to errors in judgment (error of planning such as wrong timing or failure to diagnose), and 26 percent to both manual and judgment error.</p>
<p>The most common type of manual error involved incidental injury to one of the soft internal organs such as the lungs or digestive tract (34 percent), followed by breakdown of operative repair or failure to relieve the disease (16 percent), hemorrhage (16 percent), and peripheral nerve injury (14 percent). The most common type of judgment or knowledge error was delay or error in intraoperative diagnosis or management (16 percent), such as failure to recognize a complication during the surgery.</p>
<p>Other relatively frequent judgment or knowledge errors included incorrect choice of procedure or technique (9 percent) and wrong operative site (7 percent). Only a minority of technical errors involved advanced procedures requiring special training (16 percent), surgeons inexperienced with the task (14 percent), or poorly supervised residents (9 percent). However, patient-related complexities, such as difficult or unexpected anatomy, contributed to 61 percent, and technology or systems failures contributed to 21 percent of the technical surgical errors.</p>
<p><strong>Singh, H., Thomas, E.J., Peterson, L.A., and Studdert, D.M. (2007, October). "Medical errors involving trainees: A study of closed malpractice claims from 5 insurers." <em>Archives of Internal Medicine</em> 167(19), pp. 2030-2036.</strong><br /><br />
This study found that errors in judgment, teamwork breakdowns, and lack of technical competence contribute to most of the medical errors that physician trainees make. The researchers analyzed malpractice claims from 2002 to 2004 from the files of five liability insurers to identify patient injuries due to medical error. The errors
occurred between 1979 and 2001. Among the 240 cases of harmful errors involving physician trainees, errors in judgment accounted for 72 percent, teamwork breakdowns 70 percent, and lack of technical competence 58 percent of the medical errors.</p>
<p>One-third of these medical errors resulted in significant physical injury, one-fifth in major physical injury, and one-third resulted in death. Lack of supervision and patient handoff problems were the most prevalent types of teamwork problems contributing to medical errors involving trainees versus nontrainees (54 vs. 7 percent and 20 vs. 12 percent, respectively). Judgment errors (72 percent) and failures of vigilance or memory (57 percent) were also involved in most trainee medical errors. </p> <p>
Monitoring and diagnostic decisionmaking were involved in many errors. For example, in one case, a surgical resident missed the diagnosis of a bile leak following abdominal surgery. Other significant factors contributing to trainee vs. nontrainee medical errors included: lack of technical competence (58 vs. 42 percent); lack of supervision (54 vs. 7 percent); handoff problems (19 vs. 13 percent); and excessive workload (19 vs. 5 percent).</p> <p>The collective findings from these studies should help leaders of physician residency programs to orient training interventions to these problem areas.</p>
<p class="size2"><a href=".">Return to Contents</a><br />
<a href="0308RA4.htm">Proceed to Next Article</a></p>
<p>&nbsp;</p>
<div class="footnote">
<p> The information on this page is archived and provided for reference purposes only.</p></div>
<p>&nbsp;</p>
</div>
</td>
</tr>
</table>
<!-- End of Center Content section -->
</td>
</tr>
</table>
</div>
<!-- End of Content Body -->
<!-- Footer graphic 1.2-->
<table cellspacing="0" cellpadding="0" border="0" width="100%">
<tr>
<td width="125" background="/images/bottom_ahrq_bkg.jpg"><img src="/images/bottom_ahrq_1.jpg" width="125" alt="AHRQ" /></td>
<td width="100%" background="/images/bottom_ahrq_bkg.jpg" ><img src="/images/bottom_ahrq_bkg.jpg" width="10" height="34" alt="" /></td>
<td width="310" background="/images/bottom_ahrq_bkg.jpg"><img src="/images/bottom_ahrq_2.gif" alt="Advancing Excellence in Health Care" width="310" height="34" /></td>
</tr>
</table>
<!-- Footer links section -->
<div id="banner_Footer2"><p> <a href="https://www.ahrq.gov/">AHRQ Home</a> | <a href="https://info.ahrq.gov" class="footer_navlink">Questions?</a> | <a href="https://www.ahrq.gov/contact/index.html" class="footer_navlink">Contact AHRQ</a> | <a href="https://www.ahrq.gov/sitemap.html" class="footer_navlink">Site Map</a> | <a href="https://www.ahrq.gov/policy/electronic/accessibility/index.html" class="footer_navlink">Accessibility</a> | <a href="https://www.ahrq.gov/policy/electronic/privacy/index.html" class="footer_navlink">Privacy
Policy</a> | <a href="https://www.ahrq.gov/policy/foia/index.html" class="footer_navlink">Freedom of Information Act</a> | <a href="https://www.ahrq.gov/policy/electronic/disclaimers/index.html" class="footer_navlink">Disclaimers</a> | <a href="http://www.hhs.gov/open/recordsandreports/plainwritingact/index.html" class="footer_navlink">Plain Writing Act</a> <br />
<a href="http://www.hhs.gov" class="footer_navlink">U.S. Department of Health &amp; Human Services</a> | <a href="http://www.whitehouse.gov" class="footer_navlink">The White House</a> | <a href="http://www.usa.gov" class="footer_navlink">USA.gov: The U.S. Government's Official Web Portal</a></p>
</div>
<div id="banner_Footeraddress"><p>Agency for Healthcare Research and Quality <img src="/images/bottom_dot.gif" alt="" /> 5600 Fishers Lane Rockville, MD 20857 <img src="/images/bottom_dot.gif" alt="" /> Telephone: (301) 427-1364</p></div>
<!-- End of Footer links section -->
</body>
</html>
Reference in a new issue View git blame Copy permalink