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An In Depth Investigation into Causes of Prescribing Errors by Foundation Trainees in Relation to Their Medical Education—EQUIP Study.
Dornan T, Ashcroft D, Heathfield H, et al. London: General Medical Council; 2009.
This report analyzed the causes and rates of prescribing errors in the National Health Service and found that educational level had little impact on medication errors and that many were intercepted before reaching patients. The authors suggest that a standardized national prescription chart could help prevent errors.
Journal Article > Study
Seen through their eyes: residents' reflections on the cognitive and contextual components of diagnostic errors in medicine.
Ogdie AR, Reilly JB, Pang WG, et al. Acad Med. 2012;87:1361-1367.
Diagnostic errors have been described as the next frontier in patient safety. Cognitive biases are common causes for these errors but have remained an elusive target for medical educators. This study describes an educational intervention for internal medicine residents consisting of reflective writing and facilitated small group discussions about personal experiences with diagnostic errors. Participating residents identified at least one cognitive bias and one contextual factor that may have contributed to their error. The most frequently implicated biases were anchoring and availability. Most residents also described a strategy to prevent similar errors in the future. A near miss stemming from an initial diagnostic error is highlighted in an AHRQ WebM&M commentary.
Journal Article > Study
Scott DR, Weimer M, English C, et al. Acad Med. 2011;86:742-746.
Incident reporting systems are ubiquitous in hospitals and one of the primary methods for capturing potential quality and safety issues. Physicians traditionally underutilize incident reporting systems, and in teaching institutions, the ability to engage trainees in reporting is particularly challenging. This study developed a financial incentive (i.e., retirement benefit of 1.5% of resident salary) and a multifaceted educational campaign to promote resident reporting of adverse events. Following implementation, there was a 5.6-fold increase in resident reporting with a 21% increase in near miss reports. A past AHRQ WebM&M commentary discussed the importance of reporting and creating a safe environment to encourage it.