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Journal Article > Study
Raab SS, Grzybicki DM, Zarbo RJ, Meier FA, Geyer SJ, Jensen C. Arch Pathol Lab Med. 2005;129:1246-1251.
This AHRQ-funded project describes the development of a national Web-based anatomic pathology database and how the information captured provided opportunities for intervention. Investigators first categorized the data into error types and frequency and also estimated the discrepancy rates with interpretation of recorded specimens. Subsequent root cause analyses identified system factors that contributed to the errors, and the authors share several quality improvement strategies implemented in response. While the study data derive only from self-reported institutional errors, the opportunity to expand the process to additional institutions may identify shared system deficiencies or specific error types that warrant greater attention. The process outlined resembles in many ways the efforts of reporting systems in general as a mechanism to learn and improve from past experiences with errors.
Journal Article > Commentary
Battles JB, Dixon NM, Borotkanics RJ, Rabin-Fastmen B, Kaplan HS. Health Serv Res. 2006;41:1555-1575.
This commentary discusses the concept of "sensemaking" as a mechanism to better understand and mitigate the factors that contribute to medical errors. The authors begin by presenting a conceptual framework of sensemaking before discussing both retrospective (eg, root cause analysis) and prospective (eg, failure mode and effect analysis) tools that can be employed within organizations. After discussing probabilistic risk assessment, a case example is provided to illustrate the use of these tools and what is learned from their collective findings. The authors conclude that identifying risks to patient safety represents a critical step in prevention through the design of targeted interventions.