No reduction in adverse medical events over six years despite efforts

Article found in ScienceDaily, Nov 24, 2010.

Despite concerted efforts, no decreases in patient harm were detected at 10 randomly selected North Carolina hospitals between 2002 and 2007, according to a new study from the Stanford University School of Medicine, Harvard Medical School and the Institute for Healthcare Improvement.

Since a 1999 Institute of Medicine report sounded the alarm about high medical error rates, most U.S. hospitals have changed their operations to keep patients safer. The researchers wanted to assess whether these patient-safety efforts reduced harm. They studied hospitals in North Carolina because that state has shown a particularly strong commitment to patient safety.

“We found that harm rates — in a state that was very engaged in patient safety — did not change over time. This was a little surprising to all of us,” said senior study author Paul Sharek, MD, who is an associate professor of pediatrics at Stanford and chief clinical patient safety officer at Lucile Packard Children’s Hospital. “Our findings are a call to action for the health-care system. We need a nationwide strategy for reducing harm from medical care.”

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No reduction in adverse medical events over six years despite efforts.

See Also on This Topic

The Diagnostic Error in Medicine
3rd International Conference
Toronto, Canada
October 25-27, 2010

http://www.smdm.org/diagnostic_errors/agenda_conference_schedule.shtml


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Kaveh G. Shojania, MD, Sunnybrook Health Sciences Centre

Abstract: Dr. Shojania will draw on his extensive experience in studying diagnostic error through the lens of medical autopsy (the historical gold standard for diagnostic error recognition) to reflect on the present and future of diagnostic error detection and feedback systems.

Click here to view the VIDEO for this session


Oral Abstracts: Diagnostic Reasoning, Accuracy, Tools, Errors
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Methods for Studying the Cognitive Causes of Diagnostic Error: A Systematic Review.
Martine Nurek, MSc, Brendan C. Delaney, MD and Olga Kostopoulou, PhD

Thought Process Effects in Diagnostic Decisions.
Marieke De Vries, PhD, MA, Cilia L. M. Witteman, PhD, Leontien de Kwaadsteniet, PhD, John Van den Bercken, PhD, Rob W. Holland, PhD and Ap Dijksterhuis, PhD

Diagnostic Errors in Adult Intensive Care Units: A Systematic Review of Autopsy Studies.
Bradford Winters, MD, PhD, Jason W. Custer, MD, Atul Nakhasi, B.S., Victoria Goode, B.A., Karen Robinson, B.S., David E. Newman-Toker, MD, PhD and Peter J. Pronovost, MD, PhD, FCCM

Diagnostic Errors are Common Causes of Adverse Events in Hospitalized Canadian Children.
Anne Matlow, MSc, MD, FRCPC, Catherine M. G. Cronin, MD, MBA, FRCPC, FRCPI, FAAP, Virginia Flintoft, MSc, BN, Cheri Nijssen-Jordan, MD, MBA, Mark Fleming, MA, MSc, PhD, Barbara Brady-Fryer, BSc, MN, PhD, RN, Mary-Ann Hiltz, CHIM, MHA Candidate, Elaine Orrbine and G. Ross Baker, PhD


DEM Poster Presentations
Click here to view the complete abstract for each of the 40 poster presentations


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Can Evidence-Based Medicine Help Reduce Diagnostic Error?
Click here to listen to the AUDIO Recording for this session 2 hrs
Speakers:

  • R. Brian Haynes, MD, MSc, PhD, McMaster University
  • Gordon Guyatt, BSc, MD, MSc, McMaster University
  • Barbara Bowers Jones, MLS, J. Otto Lottes Health Science Library, University of Missouri – Columbia
  • Ann McKibbon, BSc, MLS, PhD, McMaster University

Abstract: This session will include platform presentations by two of the world leaders in the science and practice of evidence-based medicine. Each will offer a unique perspective on the relationship between EBM and the future of diagnostic error reduction. Prof. Haynes will focus on the search for and synthesis of evidence related to diagnosis, while Prof. Guyatt will focus on the critical appraisal of diagnostic studies and the dissemination and teaching of EBM related to bedside diagnosis. Experts in library science will offer personal experiences and perspectives being embedded with healthcare teams to provide evidence at the bedside. A panel discussion with interactive questions and answers will follow.

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