Medical Errors

Research Findings

Research Activities, August 2008:
Part-time doctors report less burnout, greater satisfaction, and more work control than full-time physicians

Research Activities, July 2008:
AHRQ announces guide to help patients on Coumadin®/warfarin therapy
Doctors are willing to report and learn from medical mistakes, but find error-reporting systems inadequate
Most patients want doctors to disclose severe medical errors
Counting surgical sponges and instruments can prevent some being left in the patient, but better methods are needed
Intensive care nurses tend to identify patient safety practices from self-initiated tasks
Patient complaints about poor coordination of care or other services may help identify patient safety hazards
Multiple prescriptions are linked to preventable drug reactions in children
Patient safety problems are relatively infrequent among hospitalized children

Research Activities, June 2008:
When financially vulnerable rural hospitals become critical access hospitals, patient safety improves in several areas
Medical and surgical intensive care unit patients suffer from similar types of safety problems and related harm
AHRQ's patient safety indicators may be useful for comparing quality of care across delivery systems
Study shows value and limitations of voluntary error reporting systems
FDA warnings appear to lead to appropriate prescriber action

Research Activities, May 2008:
Researchers examine the relationship of workarounds to technology implementation and medication safety in nursing homes

Research Activities, April 2008:
DNA time-out procedure may help reduce patient identification error among prostate needle core biopsy specimens
Doctors override automated alerts on potential drug interactions

Research Activities, March 2008:
New patient safety proposed regulation aims to improve health care quality and patient safety
Hospital incident reporting systems often miss physician high-risk procedure and prescribing errors
Studies reveal factors contributing to technical errors in surgery and medical errors made by physician trainees
Physicians say counseling and education would be useful in reducing their stress after medical errors occur
Care quality is not necessarily better with electronic health records
Rural emergency departments have a high rate of medication errors with the potential to harm children

Research Activities, February 2008:
Physicians want to learn from medical mistakes but say current error-reporting systems are inadequate
Pediatric outpatient medication errors are common and are often due to mistakes made at home
Financial incentives to physicians and long-term care facilities may foster adoption of computerized drug systems
Observational videos can identify ways to improve emergency endotracheal intubation

Research Activities, January 2008:
AHRQ releases toolkits to help providers and patients implement safer health care practices
Studies examine pharmacy workload and medication errors and cost savings of hospital barcode medication systems
Journal supplement explores alternative research approaches to test drug safety and effectiveness
Possible problematic drug interactions are not always reported in medical records

Research Activities, December 2007:
Full disclosure of medical errors to patients is becoming more and more transparent
Many errors by medical residents are caused by teamwork breakdowns and lack of supervision
Pilot study suggests that after-hours telephone medical consultations may pose risks to patient safety
A pharmacy alert system plus physician-pharmacist collaboration can reduce inappropriate drug prescribing among elderly outpatients
AHRQ releases a new DVD about designing hospitals for safety and quality

Research Activities, November 2007:
Nursing home report cards have prompted many nursing homes to improve care, especially those with poor scores
Studies explore the use and functions of electronic health records
Implementing a basic electronic prescribing system may reduce nonclinical prescribing errors

Research Activities, October 2007:
Studies funded by AHRQ's Primary Care Practice-Based Research Networks (PBRNs) identify ways to improve patient care and report medical errors
Studies examine dispensing of sample medications and preventing medication errors in primary care practices

Research Activities, September 2007:
Medication errors are made during care for half of the children seen at rural California emergency departments
Hospitals that operate at or over capacity are more likely to have patient safety problems
Outpatient medication errors are common among patients who have received liver, kidney, and/or pancreas transplants
Computerized drug-drug interaction alerts are useful, but can be improved

Research Activities, August 2007:
More than one-third of hospitalized patients are concerned about medical errors, which they define more broadly than clinicians
Over half of missed diagnoses in the emergency department alleged in malpractice claims resulted in harm to patients
Few of the safeguards routinely used for intravenous chemotherapy have been adopted for oral chemotherapy at U.S. cancer centers

Research Activities, July 2007:
Certain resident and facility characteristics and medications increase the risk of fractures among nursing home residents

Research Activities, June 2007:
Reduced payments to hospitals may jeopardize patient safety
Medication errors are common among patients in psychiatric hospitals
AHRQ's annual State Snapshots highlight States' gains and lags in health care quality
New Web tool provides samples of report cards on health care quality
New resource offers suggestions for improving the safety in health care environments

Research Activities, May 2007:
Studies examine how to improve patient safety with instructional systems design
Examining use of "rescue drugs" in a hospital can reveal previously unreported adverse drug events
Hand washing, barrier protection, and other procedures can reduce catheter-related bloodstream infections in the ICU
Applying strategies that focus on laboratory specimen labeling errors can significantly reduce specimen identification errors

Research Activities, April 2007:
Automated piggyback infusion of intravenous drugs is neither simple nor safe
Many transplant surgeons are inadequately vaccinated against the hepatitis B virus, exposing themselves and patients to infection

Research Activities, March 2007:
AHRQ and the Ad Council encourage patients to ask questions and get more involved with their health care
Barriers impede efforts to use a region-wide hospital medication error reporting system
Emergency departments with physician residents are less effective in determining which children require hospital admission
Use of the pain reliever propoxyphene is associated with a higher risk of hip fracture among the elderly

Research Activities, February 2007:
Diagnostic errors that harm outpatients are typically the result of multiple individual and system breakdowns
Shifting from a culture of blame to a culture of safety in nursing homes could help identify and prevent medical errors
Few patients seek compensation for medical injuries through New Zealand's no-fault medical malpractice system
Not adjusting for pre-existing health problems may have exaggerated the number of deaths due to medical injury
A small proportion of patients are prescribed a medication that can interact with the QT-prolonging medication they also take
Eleven medications account for one-third of medication errors that harm hospitalized children

Research Activities, January 2007:
Physicians' extended work shifts are associated with increased risks of medical errors that harm patients
Extended resident work hours jeopardize both resident health and patient safety
Health systems dedicated to improving patient safety are beginning their journey and need a roadmap to prioritize initiatives
Studies reveal that error disclosure is similar among American and Canadian doctors, despite different malpractice environments
Identifying patients' medical conditions at hospital admission provides a more accurate picture of hospital performance

Research Activities, December 2006:
Both hospitals and Medicare would gain financially by improving patient safety
Medical injuries among children result in longer hospital stays and higher charges
Clinician communication through multidisciplinary rounds may improve with well-designed information tools

Research Activities, November 2006:
New patient safety team training toolkit available for health care settings
Coverage that allows interns to nap during extended shifts can increase their sleep time and decrease fatigue
Patient safety indicators are useful tools for tracking and monitoring patient safety events

Research Activities, October 2006:
Organizational silence threatens patient safety
Medical malpractice laws capping damage payments appear to lower State health care expenditures by 3 to 4 percent
Over half of compensation for medical malpractice claims goes toward administrative expenses

Research Activities, September 2006:
National studies examine excess work hours among medical interns and the risk for needlestick injuries
Patients are willing to help prevent medical errors, but reluctant to take all the recommended actions
Survey suggests that hospitals in Iowa have made the most progress in following long-standing safe practices
Using handheld computers with specific prescribing software at the point of care can reduce unsafe NSAID prescribing

Research Activities, August 2006:
Studies examine the safety climate and teamwork in hospital operating rooms
Long work hours and family care-giving affect nurses' hospital performance
Pharmacists help identify patient safety and quality issues by clarifying prescriptions
Hospital pharmacy medication dispensing is highly accurate, but still inadequate
Studies examine the source of diagnostic errors in thyroid and lung cancers
Studies examine the practice of prescribing medications to outpatients that can dangerously interact with one another

Research Activities, July 2006:
NICU babies are frequently at risk for misidentification
Surgeons vary widely in their approaches to disclosing medical errors to their patients
Computerized prescribing may reduce some harmful medication errors, but can introduce new errors
Paramedic errors in lifesaving endotracheal intubation may be a symptom of larger emergency medical system problems

Research Activities, June 2006:
Hospital patient safety systems show moderate progress in meeting Institute of Medicine recommendations

Research Activities, May 2006
Accidental lung puncture is a substantial threat to hospitalized patients undergoing a wide range of procedures

Research Activities, April 2006
AHRQ study finds wrong-site surgery is rare and preventable
Patient responses to medical errors depend on the timeliness and quality of the physician's communication about the event
Immediate interpretation of lung tissue samples and use of transmucosal fine-needle aspiration reduces pathology errors
Over one-third of outpatients prescribed drugs for the first time do not receive recommended laboratory monitoring
Although inappropriate for use in older adults, propoxyphene was widely prescribed to elderly patients in the 1990s

Research Activities, March 2006
Frequent potential medication dosing errors occur during outpatient pediatric visits
Close-call reporting systems may be underutilized in identifying potential medical errors
Patient responses to medical errors depend on the timeliness and quality of the physician's communication about the event

Research Activities, February 2006:
Excessive nurse workload is a key factor affecting the safety of patients in intensive care units
Consumers are unlikely to engage in protective behaviors to prevent medical errors
Up to 12 percent of tissues examined by pathologists for cancer result in diagnosis errors
Study provides estimates of cervical cancers that may be missed by extending screening time after consecutive negative Pap smears
The new Medicare drug bill encourages E-prescribing to improve patient safety and health, but advanced systems are key
Computerized physician order entry prevents drug errors, but can initially result in new errors in ICUs

Research Activities, January 2006:
National anatomic pathology errors database can reduce hospital pathology errors

Research Activities, December 2005:
Hospitalized patients can help improve patient safety by identifying medical errors not captured by hospital systems
Patient Safety Indicators may be useful screening tools in Veterans Health Administration hospitals

Research Activities, November 2005:
Real-time safety audits can detect a broad range of errors in neonatal intensive care units
Physician knowledge and skills and team communication improve safety in intensive care units
Web-based patient safety education curriculum incorporates suggestions from physicians, nurses, and patients
Study discusses the legal aspects of providers sharing information on medical errors
Patient safety problems increase when hospital profit margins decline over time

Research Activities, October 2005:
Study investigates PDA software applications that can optimize medication safety
One percent of Americans visit doctors each year to manage health problems caused by medication

Research Activities, September 2005:
Patients in intensive care units are at significant risk for adverse events and serious errors

Research Activities, August 2005:
Resident work hour limits in New York teaching hospitals were not associated with improved safety for surgery patients
One hospital's experience suggests that communication problems may underlie a substantial number of hospital adverse events
Hospital fall prevention programs should target certain patient, medication, and care-related factors that increase falling risk

Research Activities, July 2005:
Adverse drug events occur frequently in long-term care facilities, and nearly half of them are preventable
Linking lab and pharmacy databases can help identify patients who don't undergo followup for abnormal tests
Radiologists with more experience reading mammograms aren't necessarily more accurate in interpreting them
New Web-based ICU safety reporting system may have the potential to reduce medical errors at ICUs across the country
Executive walk rounds are a promising tool for improving the safety climate of hospitals

Research Activities, June 2005:
Nurses can take steps to prevent pediatric medication errors associated with dosing and administration
Limiting residents' work hours may have unintended consequences on continuity of care
Better monitoring of outpatients taking thyroid replacement therapy may reduce drug-related problems
One-third of a national sample of hospital staff nurses made an error or near error over a 1-month period
Partnering with hospitalized patients to monitor medication use is a feasible strategy for reducing drug errors

Research Activities, May 2005:
Survey reveals that hospital leaders are concerned about the impact of mandatory error-reporting systems
Despite promising efforts over the past 5 years to improve patient safety, the American public does not feel safer

Research Activities, April 2005:
Study documents the prescribing of potentially harmful drugs to elderly outpatients prescribed multiple drugs
ICU patients are at risk for unintended and preventable adverse events involving airway management
Smart intravenous infusion systems have the potential to reduce serious medication errors in ICUs
Hospital readmission for venous thromboembolism among postoperative patients may signal quality of care problems

Research Activities, March 2005:
New study on computerized order entry finds flaws that could lead to errors, but there are opportunities for improvement

Research Activities, February 2005:
Policies are being considered to extend medical malpractice tort reforms to the nursing home sector

Research Activities, January 2005:
Medical interns who work extended-duration shifts double their risk of car crashes when driving home from the hospital
Voluntary primary care safety reporting system includes errors due to communication, diagnostic tests, and medication
Clinicians value medication safety alerts and welcome small-group training to make better use of them

Research Activities, December 2004:
Results of a consumer survey on patient safety present both an opportunity and a challenge to make health care safer
Anonymity, feedback, and a blame-free environment promote reporting of medical errors
Many primary care errors stem from problems with access to clinicians and doctor/patient interaction
Improving nurses' working conditions can potentially decrease the incidence of many infectious diseases
Underreporting of medical errors affecting children is a significant problem, particularly among physicians

Research Activities, November 2004:
Limiting medical interns' work to 16 consecutive hours can substantially reduce serious medical errors in ICUs
Researchers examine factors that affect voluntary reporting of medication errors

Research Activities, October 2004:
Extended work shifts, common among nurses, substantially increases the likelihood of medical errors
Physicians say they favor disclosure of medical errors to patients and families, but disclosure often does not occur

Research Activities, September 2004:
Root cause analysis should be conducted after a wrong site surgery to reduce future errors
Hospital providers' understanding of patient safety is heavily influenced by their professional roles
In certain situations, nurses should raise a "red flag" to protect patient safety
Researchers examine the challenges of ensuring the safety of cardiovascular devices

Research Activities, August 2004:
Medication errors are frequent in the emergency department and often arise from the fast pace and heavy patient load
Teaching anesthesia during surgery may be a distraction that reduces the vigilance of anesthesia care

Research Activities, July 2004:
Medical errors appear to be common among ICU patients, and a simple blame-free reporting system can help identify them
A pain in the neck could mean Lemierre's syndrome

Research Activities, June 2004:
Children in hospitals frequently experience medical injuries
Doctors' disclosure of medical errors improves patient satisfaction but may not prevent legal action
Hospital workers worry about patient safety at their hospitals and look to hospital leaders for a commitment to safety
Researchers identify five information technologies that have great potential to improve patient safety for children

Research Activities, May 2004:
Conference participants outline research agenda for pediatric outpatient safety

Research Activities, February 2004:
Computerized physician order entry needs further refinement to substantially reduce medication errors in primary care

Research Activities, January 2004:
Interdisciplinary teamwork is a key to patient safety in the operating room, ICU, and ER
Using chlorhexidine gluconate solution for vascular catheter site care greatly reduces the risk of catheter-related infection