Article Text
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
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↵* See end of article for list of members of Medical Emergency Response Improvement Team.
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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.
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See editorial commentary, p 247