Classics and Emerging Classics

This article explains a prospective study at an academic hospital studying adverse events in 400 consecutive patients after discharge from a medical service. The authors describe the incidence, severity, and preventability of reported events along with specific examples captured during the study. They discuss strategies to improve patient safety by emphasizing the vulnerability of the discharge transition from hospital to home. The study identifies an important target for future interventions by suggesting improvement in the coordination and follow-up of care immediately after hospital discharge.

The author shares the unique perspectives of a patient and his wife as they navigate through a hospitalization. The patient and his wife provide a diary of their experiences from checking in at the hospital, to waiting in recovery for a floor bed, to being cared for on the floor, and, finally, to the discharge process. A nurse manager and CEO of the same institution offer their insight into the inefficiencies and concerns for safety identified by the patient. The documented exchange provides readers with a patient’s perspective on the shortcomings of the hospital experience and how much of it is due to failed systems and not failed providers. This article is part of a special collection entitled “Quality Grand Rounds,” a series of articles published in the Annals of Internal Medicine that explores a range of quality issues and medical errors.

This study reports the findings from interviews with 139 anesthesiologists, residents, and nurse-anesthetists about their observation of errors. The authors describe characteristics from more than 1000 incidents collected and offer strategies to both detect and prevent future ones. Based on the patterns noted, the discussion suggests that human error played a dominant role in the reported incidents. The authors conclude that it may be beneficial to classify specific incidents by a preventive strategy, rather than one based on outcomes, in order to prevent future adverse events and provide more constructive learning from previous errors.

A retrospective analysis of the American Society of Anesthesiology Closed Claims Study, this article describes the types of adverse outcomes for which claims were filed. The authors report that three mechanisms of injury (inadequate ventilation, esophageal intubation, and difficult tracheal intubation) accounted for three-fourths of the adverse respiratory events. They further describe the median costs of settlements awarded, characteristics of events in which care was deemed substandard, and claims in which the outcome was considered preventable. The authors advocate for a better understanding of respiratory risks and methods to more quickly collect data upon recognition of an adverse outcome.

This review discusses the psychology of human error in the context of anesthesia. The authors provide definitions of, and describe the relationships between, errors, incidents, and accidents while drawing examples from the Australian Incident Monitoring Study. They explore a classification system for errors, including discussion of relevant taxonomic forms of “active” errors and contributing factors to “latent” errors. The discussion continues with strategic suggestions to both reduce and manage errors, which entail adequate collection, organization, and analysis of reported and recorded events. The authors also advocate for systematic understanding of errors as catalysts for future prevention efforts.

Perhaps the first of its kind in the early 1960s, this study explored the methods and challenges of identifying medication errors. Targeting registered nurses as a source for data collection, the investigators studied direct observation, self-report, and existing incident reports to compare strategies for effective error detection. The authors review the definition and types of medication errors before presenting findings from their contrasting data collection methods. Conclusions suggest that direct and disguised observation may be the best method for estimating medication errors, and that previous efforts to assess the prevalence of the problem are likely understated.

This article is a review and analysis of the Mann Gulch fire disaster, an event made famous in Norman Maclean's award–winning book, Young Men and Fire (1992). Using the story of a firefighter who improvised a response to a fire by setting a back-fire while the rest of his crew panicked and ultimately perished, Weick examines the disintegration of role structure and sensemaking within an organization. He discusses sources of resilience that make groups less vulnerable, including improvisation, virtual role systems, the attitude of wisdom, and norms of respectful interaction. The purpose is to understand why organizations unravel and how they become more resilient. The organizational literature is reviewed to demonstrate a need for reexamination of successful group structures. Weick's work influenced many others who have written about improving safety, particularly in teams that work in fast-moving and ambiguous clinical settings.

This article summarizes a series of cognitive error types referred to as “cognitive dispositions to respond” (CDRs). The author reviews previously described CDRs, such as failures in perception and heuristics, overconfidence bias, and anchoring. He aims to provide a detailed perspective on the cognitive challenges that impact diagnostic decision making, including strategies to handle them. The author concludes that in order to reduce diagnostic errors, further investigation must pursue effective methods of “cognitively debiasing” ourselves when making clinical decisions.

This study of anesthesiology residents demonstrated that fatigue negatively impairs psychomotor functioning and mood but not measures of clinical performance. Investigators examined, scored, and analyzed the observed behaviors of 12 residents in differing states of prior sleep. The findings support the notion that fatigue can lead to errors as a result of impaired cognitive abilities even if the more difficult to measure clinical performance outcomes were less affected. These findings are the first from a comprehensive simulation study addressing the effects of provider fatigue.

This AHRQ-funded study demonstrated that the risk of error increased in association with extended work shifts, overtime, or longer than 40-hour work weeks. Using logbooks from nearly 400 nurses sampled out of a larger group from the American Nurses Association, investigators determined that an alarmingly high percentage of nurses report working extended hours. For those shifts longer than 12.5 hours, the error rate increased notably. The authors advocate for continued attention to relationships between nursing work hours and patient safety, building on past research that linked staffing to poor patient outcomes.