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3 September 2002 | Volume 137 Issue 5 Part 1 | Pages 327-333
When a patient with multiple, complicated conditions is admitted to a hospital and risky procedures are performed that result in adverse outcomes, the difficulties inherent in determining whether and when a preventable medical error has occurred must be addressed. This article analyzes the case of a 40-year-old woman with a history of chronic aortic dissection and pericardial effusion who was admitted to a teaching hospital with unilateral swelling of her left breast and arm accompanied by dyspnea. During her hospitalization, the patient developed multiple complications from the diagnostic and therapeutic procedures that were performed. The authors argue that this case illustrates some limitations of routinely undertaking time-consuming and costly reviews, or "root-cause analyses," as a patient safety strategy when they are unlikely to reveal remediable "errors" or to suggest better systems of care that will prevent errors. The ability to establish causality through post hoc reviews is the linchpin in the recommendation for widespread adoption of error reporting and reviews. When causality is not established, it is impossible to know whether any changes adopted as a result of the reviews will be effective. This case, in which the causal pathways to the adverse events are very uncertain, may be much more typical than the egregious errors featured in a classic root-cause analysis. The authors recommend that the relative merits of this approach to patient safety be compared with other proven, cost-effective interventions to improve quality, such as appropriate treatment of myocardial infarction or depression, before scarce resources and enormous human capital are allocated for widespread implementation.
Author and Article Information
From the VA Center for Practice Management and Outcomes Research and the Quality Enhancement Research Initiative (QUERI), VA Ann Arbor Healthcare System; and University of Michigan School of Medicine and School of Public Health, Ann Arbor, Michigan.
*This paper was prepared by Timothy P. Hofer, MD, MS, and Rodney A. Hayward, MD, for the Quality Grand Rounds series. Kaveh G. Shojania, MD, and Sanjay Saint, MD, MPH, prepared the case for presentation.
Grant Support: Funding for the Quality Grand Rounds series is supported by the California HealthCare Foundation as part of its Quality Initiative. Dr. Hofer is supported by a Career Development Grant from Health Services Research and Development, Office of the Department of Veterans Affairs (RCD 91-303).
Requests for Single Reprints: Timothy P. Hofer, MD, MS, PO Box 130170, Ann Arbor, MI 48113-0170; e-mail, thofer{at}umich.edu.
Current Author Addresses: Drs. Hofer and Hayward: PO Box 130170, Ann Arbor, MI 48113-0170. ACADEMIA AND CLINIC
QUALITY GRAND ROUNDS
Series Editors: Robert M. Wachter, MD; Kaveh G. Shojania, MD; Sanjay Saint, MD, MPH; Amy J. Markowitz, JD; and Mark Smith, MD, MBA
Are Bad Outcomes from Questionable Clinical Decisions Preventable Medical Errors? A Case of Cascade Iatrogenesis
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