Tables 2A and 2B:
Types and contributing factors of events described by respondents
| Mistake type and definition[21,22] | Respondents describing mistake, No. (%) (n=1556) |
Representative Quoteg |
|---|---|---|
| Treatment | 976 (63) | “I was in residency, MICU consults. Called to assess a healthy…woman who was…dyspneic and hypoxic. We found she had a large PE. No room in MICU so moved her to cardiac step-down w a/c. I passed her on to the floor team. Heard in the AM she crashed overnight and was unable to be resuscitated. I wasn’t there but can’t shake feeling I could have done more for her.” “Medication error. Multifactorial, but final call was my call and my error.“ |
| Error in the performance of an operation, procedure, or test | ||
| Error in administering the treatment | ||
| Error in the dose or method of using a drug | ||
| Avoidable delay in treatment or in responding to an abnormal test | ||
| Inappropriate (not indicated) care | ||
| Diagnostic | 459 (30) | “Missed an abnormal…finding that was later picked up by my peer while I was on maternity leave. No change in patient outcome but every time I see that patient, I feel disappointed and inadequate.” “I delayed diagnosis of a surgical emergency. It was not something I’d seen before and was afraid to wake up surgeon because I was not sure. I admitted the patient but surgical management was delayed by several hours.” |
| Error or delay in diagnosis | ||
| Failure to employ indicated tests | ||
| Use of outmoded tests or therapy | ||
| Failure to act on results of monitoring or testing | ||
| Preventive | 18 (1) | “Patient not put on appropriate antimicrobial prophylaxis.” “[Drug] toxicity in a patient I had not checked a level on in awhile (6 months).” |
| Failure to provide prophylactic treatment | ||
| Inadequate monitoring or follow-up of treatment | ||
| Other: other system failure | 35 (2) | “pharmacy dispensed different drug than what we ordered.” “I recently posted the results on a series of wrong (sic) patients thanks to the emr that I got no live training for and no training on desktop mgt. My staff caught it…I do not think this caused harm but did cause stress to me.“ |
| Other: failure of communication | 34 (2) | “It was a system error. I never received test results from radiology on a patient in clinic. The patient called a month later asking about CT results and they were abnormal. We didn’t have a a good system in place at the time to ensure that never happened. We do now.” “Was not called on a CT result for a week. I may not have been fully responsible but I felt sick when I found out. “ |
| Other: equipment failure | 8 (1) | “Trach, vent dependent…pt went into severe respiratory distress & Bradycardia. He was coded for an hour. Tried to externally pace but I feel that the pacer was not delivering shocks. Nurse said it was working fine. Still disagree…Not even sure if he is still alive” “Surgical error--broken sheath when equipment being removed” |
| Unknown | 26 (2) | “Felt I had to do something I was uncomfortable doing.” “Exhausted, end of 18 hour day, after a weekend on call. Or was getting sick, I knew something was wrong, but was literally too tired to realize what the problem was. Only after M&M conference was I able to realize it wasn’t a knowledge deficit, just an exhaustion issue.” |
| Contributing factors and definition[23] |
Respondents describing mistakeh, No. (%) (n=1556) |
Representative Quoteg |
|---|---|---|
| Cognitive | 1215 (78) | “Missed a lung ca in a pt complaining of sob and palpitations bc I got so sidetracked…“ “This wasn’t recent but it’s the one that haunts me. While intubating a [patient]…in medical school, I was handed a packaged LMA and didn’t realize there’s a plastic cap over the bottom, which I inserted into the patient, who desaturated very temporarily and had a scrape to the airway… |
| Judgment | ||
| Vigilance or memory | ||
| Lack of knowledge | ||
| Other systems | 573 (37) | “I was a second year IM resident on call alone…A patient needed to have an airway secured for sedation, and I was unable to obtain the airway. We had no backup….” “Wrong medication dosage. Felt likely due to multiple physician interruptions during the day, breaking concentration, and increasing risk of writing the wrong dose.“ |
| Lack of supervision | ||
| Workload | ||
| Interruptions | ||
| Technology problems | ||
| Fatigue | ||
| Communication | 288 (19) | “Wrong dose of insulin given in the OR because I did not effectively communicate with the resident who was assisting me in the case“ “Retained lap. Count done incorrectly“ |
| Handoffs | ||
| Failure to establish clear lines of responsibility | ||
| Conflict | ||
| Some other failure of communication | ||
| Patient-related | 171 (11) | “pt lost to follow up. i’m pretty sure had…ca [cancer]. i should have called her more and made sure she did her imaging. should have been more clear about my concerns for her: maybe she didn’t understand?“ “Patient did not do full work up I recommended and I didn’t push for frequent enough followup“ |
| Nonadherence | ||
| Atypical presentation | ||
| Complicated medical history | ||
| Information about medical history of poor quality | ||
| Other | ||
| Technical | 148 (10) | “Bowel perforation during elective robotic surgery“ “Incidental bladder injury during c-section“ |
| Unknown | 212 (14) | “Complication of a procedure. Patient coded and died.” “Bad heart tracing-don’t know why. Not sure anything could have been done differently, but makes you wonder. “ |
g
Although no identifying information was collected, authors redacted information from free text descriptions of mistakes if any potentially identifiable details were included
h
Authors assigned multiple contributing factors to each response, when applicable, therefore percentages do not add to 100%