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- Error Reporting and Analysis
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Robert J. Weber, PharmD, MS; February 2010
An elderly woman presented to the emergency department following a hip fracture. Although the patient's medication bottles were used to generate a medication list, one of the dosages was transcribed incorrectly. Because the patient then received four times her regular dose, her surgery was delayed due to cardiac side effects.
Journal Article > Study
Stahel PF, Flierl MA, Smith WR, et al. Am J Med Qual. 2010;25:398-401.
An orthopedic surgery department implemented a confidential, real-time system for reporting intraoperative adverse events and analyzed these events in structured morbidity and mortality conferences. Although physicians felt this process improved patient care, it resulted in a significant increase in reported error rates, which, as the authors point out, could have resulted in lower quality ratings for the department.