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Use of medical emergency team (MET) responses to detect medical errors
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  1. R S Braithwaite3,
  2. M A DeVita1,
  3. R Mahidhara2,
  4. R L Simmons2,
  5. S Stuart4,
  6. M Foraida4,
  7. and members of the Medical Emergency Response Improvement Team (MERIT)*
  1. 1Patient Safety Program, Department of Critical Care Medicine, University of Pittsburgh Medical Center Presbyterian Hospital, Pittsburgh, PA, USA
  2. 2Patient Safety Program, Department of Surgery, University of Pittsburgh Medical Center Presbyterian Hospital, Pittsburgh, PA, USA
  3. 3Patient Safety Program, Department of Internal Medicine, University of Pittsburgh Medical Center Presbyterian Hospital, Pittsburgh, PA, USA
  4. 4University of Pittsburgh Medical Center Presbyterian Hospital, Pittsburgh, PA, USA
  1. Correspondence to:
 Dr M A DeVita
 University of Pittsburgh Medical Centre Presbyterian Hospital, 200 Lothrop Street, Pittsburgh, PA 15213, USA; devitammsx.upmc.edu

Abstract

Background: No previous studies have investigated whether medical emergency team (MET) responses can be used to detect medical errors.

Objectives: To determine whether review of MET responses can be used as a surveillance method for detecting medical errors.

Methods: : Charts of all patients receiving MET responses during an 8 month period were reviewed by a hospital based Quality Improvement Committee to establish if the clinical deterioration that prompted the MET response was associated with a medical error (defined as an adverse event that was preventable with the current state of medical knowledge). Medical errors were categorized as diagnostic, treatment, or preventive errors using a descriptive typology based on previous published reports.

Results: Three hundred and sixty four consecutive MET responses underwent chart review and 114 (31.3%) were associated with medical errors: 77 (67.5%) were categorized as diagnostic errors, 68 (59.6%) as treatment errors, and 30 (26.3%) as prevention errors. Eighteen separate hospital care processes were identified and modified as a result of this review, 10 of which involved standardization.

Conclusions: MET review may be used for surveillance to detect medical errors and to identify and modify processes of care that underlie those errors.

  • error detection
  • error prevention
  • medical emergency team
  • medical error

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Footnotes

  • * See end of article for list of members of Medical Emergency Response Improvement Team.

  • MERIT Committee: D Annonio RN, N Bircher MD, K Castelnuovo, C Colleen, K Drain, G Gotaskie RN, W Grbach RN, C Griffin RN, L Haas RN, J Hanna RN, C Herisko MSN, RN, M Hudak RN, D Konop RN, J Kowiatek PharmD, P Matthews RN, J McWilliams RN, N Mininni MSN, RN, V Mossesso MD, P Natale RN, P O’Driscoll, J Phillips, C Schollee RN, D Shearn RN, T Smitherman MD, S Svec RN, V Tappe RN, A Towers MD, J Turka RN, D Zimmer RN.

  • See editorial commentary, p 247

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