A reduction in errors is associated with prospectively recording them

Abstract

Object Error recording and monitoring is an important component of error prevention and quality assurance in the health sector given the huge impact of medical errors on the well-being of patients and the financial loss incurred by health institutions. With this in mind, assessing the effect of reporting errors should be a cause worth pursuing. The object in this study was to examine the null hypothesis that recording and publishing errors do not affect error patterns in a clinical practice. Methods Intraoperative errors and their characteristics were prospectively recorded between May 2000 and May 2013 in the neurosurgical practice of the senior author (M.B.). The error pattern observed between May 2000 and August 2006, which has been previously described (Group A), was compared with the error pattern observed between September 2006 and May 2013 (Group B). Results A total of 1108 cases in Group A and 974 cases in Group B were surgically treated. A total of 2684 errors were recorded in Group A, while 1892 errors were recorded in Group B. The ratios of cranial to spinal procedures performed in Groups A and B were 3:1 and 10:1, respectively, while the ratios of general to local anesthesia in the two groups were 2:1 and 1.3:1, respectively (p < 0.0001 for both). There was a significantly decreased proportion of cases with error (87% to 83%, p < 0.006), mean errors per case (2.4 to 1.9, p < 0.0001), proportion of error-related complications (16.7% to 5.5%, p < 0.002), and clinical impacts of error (2.7% to 1.0%, p < 0.0001) in Group B compared with Group A. Errors in Group B tended to be more preventable than those in Group A (85.8% vs 78.5%, p < 0.0001). A significant reduction was also noticed with most types of error. A descending trend in the mean errors per case was demonstrated from the years 2001 to 2012; however, an increased severity of errors (22.6% to 29.5%, p < 0.0001) was recorded in Group B compared with Group A. Conclusions Data in this study showed that the act of recording errors might alter behaviors, resulting in fewer errors.

Prospectively Recording Errors Is Valuable in Reducing Complications

“…Prospective error recording makes it possible to establish the causal pathway for the occurrence of specific errors with accuracy, which could also play a significant role in providing preventive measures and changes in protocols to help improve the quality of care [14]- [16]. The actual process of documentation and recording of errors prospectively is important in order to gain access to real time occurrences as well as enhance the accuracy and details of each event [11] [12]. When errors are prospectively recorded it allows for the involvement of all team members and increases their sense of responsibility and communication not just with the patient, but with each other.…”

“…A recent study by Oremakinde and Bernstein [11] showed the importance and impact of prospective error recording. The error types that were recorded prospectively include technical, contamination, nursing, anesthesia, management/judgment, and communication/information errors [11]. They found that, overtime these types of errors had significantly declined [11].…”

“…The error types that were recorded prospectively include technical, contamination, nursing, anesthesia, management/judgment, and communication/information errors [11]. They found that, overtime these types of errors had significantly declined [11]. Two time epocs were compared.…”

Legal perspectives on black box recording devices in the operating environment

“…A MDR is able to record operational data (for example from overview cameras, laparoscopic cameras, anaesthetic and environmental equipment), enabling analysis of technical and non‐technical elements. It provides theatre staff the opportunity to learn from their performance or suboptimal situations to enhance team performance. Surgical procedures may be recorded for purposes of education, research and quality improvement.…”

“…Surgical procedures may be recorded for purposes of education, research and quality improvement. Although this has been associated with a reduction in errors, there are concerns about the adequacy of implementation related to privacy, ownership of data and medical negligence. Understandably, medical practitioners fear that a MDR could be misused for punitive or controlling purposes, a situation that inevitably leads to scepticism, user resistance and loss of autonomy.…”