An Error Reduction Initiative

Abstract

Medical errors kill many Americans each year. Information on sentinel events gathered at military hospitals is typically presented as numerator data without much analysis. Fearing litigation and blame, health care providers appear to be reluctant to report on "near misses" where errors have occurred, but not resulted in actual harm. Using a non-punitive approach, anesthesiologists championed a method to learn from errors in order to improve patient outcomes. This graduate management project involves analysis of trends and error rates in the risk management database of Winn Army Community Hospital. Numbers of incident reports were compared before and after educational interventions to increase voluntary reporting. Numbers of prescription edits were quantified and compared before and after default prescriptions were introduced to decrease errors. Recommendations were made about efforts which may best serve an effective error reduction initiative.

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Document Details

Document Type
Technical Report
Publication Date
Apr 06, 2001
Accession Number
ADA420418

Entities

People

  • Paula K. Underwood

Organizations

  • Academy of Health Sciences

Tags

DTIC Thesaurus Topics

  • Ear
  • Ear Diseases
  • Health Care
  • Health Services
  • Medical Personnel
  • Pain
  • Patient Care
  • Physicians
  • Risk
  • Therapy
  • Wounds And Injuries

Fields of Study

  • Medicine

Readers

  • Aviation Safety Risk Assessment.
  • Educational Psychology
  • Medical or Health Care Field.