Skip to main content

Advertisement

Log in

Sins of omission

Getting too little medical care may be the greatest threat to patient safety

  • Original Articles
  • Published:
Journal of General Internal Medicine Aims and scope Submit manuscript

Abstract

BACKGROUND: Little is known about the relative incidence of serious errors of omission versus errors of commission.

OBJECTIVE: To identify the most common substantive medical errors identified by medical record review.

DESIGN: Retrospective cohort study.

SETTING: Twelve Veterans Affairs health care systems in 2 regions.

PARTICIPANTS: Stratified random sample of 621 patients receiving care over a 2-year period.

MAIN OUTCOME MEASURE: Classification of reported quality problems.

METHODS: Trained physicians reviewed the full inpatient and outpatient record and described quality problems, which were then classified as errors of omission versus commission.

RESULTS: Eighty-two percent of patients had at least 1 error reported over a 13-month period. The average number of errors reported per case was 4.7 (95% confidence intervals [CI]: 4.4, 5.0). Overall, 95.7% (95% CI: 94.9%, 96.4%) of errors were identified as being problems with under-use. Inadequate care for people with chronic illnesses was particularly common. Among errors of omission, obtaining insufficient information from histories and physicals (25.3%), inadequacies in diagnostic testing (33.9%), and patients not receiving needed medications (20.7%) were all common. Out of the 2,917 errors identified, only 27 were rated as being highly serious, and 26 (96%) of these were errors of omission.

CONCLUSIONS: While preventing iatrogenic injury resulting from medical errors is a critically important part of quality improvement, we found that the overwhelming majority of substantive medical errors identifiable from the medical record were related to people getting too little medical care, especially for those with chronic medical conditions.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Tversky A, Kahneman D. Loss aversion in riskless choice: a reference-dependent model. Q J Econ. 1991;106:1039–61.

    Article  Google Scholar 

  2. Kahneman D, Tversky A. Prospect theory: an analysis of decision under risk. Econometrica. 1979;ALVII:263–91.

    Article  Google Scholar 

  3. Kahneman D, Tversky A. The simulation heuristic. In: Judgment Under Uncertainty: Heuristics and Biases. New York: Cambridge University Press; 1982.

    Google Scholar 

  4. Spranca M, Minsk E, Baron J. Omission and commission in judgement and choice. J Exp Soc Psychol. 1991;27:76–105.

    Article  Google Scholar 

  5. Ritov I, Baron J. Reluctance to vaccinate: omission bias and ambiguity. J Behav Decis Making. 1990;3:263–77.

    Google Scholar 

  6. Asch DA, Baron J, Hershey JC, et al. Omission bias and pertussis vaccination. Med Decis Making. 1994;14:118–23.

    Article  PubMed  CAS  Google Scholar 

  7. Institute of Medicine. To Error is Human: Building a Safer Health System. Washington, DC: National Academy Press; 1999.

    Google Scholar 

  8. Millenson ML. Pushing the profession: how the news media turned patient safety into a priority. Qual Safety Health Care. 2002;11:56–63.

    Google Scholar 

  9. Dentzer S. Media mistakes in coverage of the Institute of Medicine’s error report. Eff Clin Pract. 2000;3:305–8.

    PubMed  CAS  Google Scholar 

  10. American Iatrogenic Association Library. Information that improves understanding of medical error, philosphy, and practice. Accessed February 21, 2004: http://www.iatrogenic.org/library/mederrorlib.html

  11. The Leapfrog Group. Patient safety. Accessed February 21, 2004: http://www.leapfroggroup.org/safety.htm

  12. Wachter RM, Shojania KG. Internal Bleeding: The Truth Behind America’s Terrifying Epidemic of Medical Mistakes. New York: Rugged Land. LLC; 2004.

    Google Scholar 

  13. Brook RH. Quality of care: do we care? Ann Intern Med. 1991;115:486–90.

    PubMed  CAS  Google Scholar 

  14. Chassin MR, Galvin RW. The urgent need to improve health care quality. Institute of Medicine National Roundtable on Health Care Quality. JAMA. 1998;280:1000–5.

    Article  PubMed  CAS  Google Scholar 

  15. Committee on Quality of Health Care in America: Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press.

  16. Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients. N Engl J Med. 1991;324:370–6.

    PubMed  CAS  Google Scholar 

  17. Thomas EJ, Studdert DM, Burstin HR, et al. Incidence and types of adverse events and negligent care in Utah and Colorado. Med Care. 2000;38:261–71.

    Article  PubMed  CAS  Google Scholar 

  18. Gandhi TK, Weingart SN, Borus J, et al. Adverse drug events in ambulatory care. N Engl J Med. 2003;348:1556–64.

    Article  PubMed  Google Scholar 

  19. Hayward RA, Hofer TP. Estimating hospital deaths due to medical errors: preventability is in the eye of the reviewer. JAMA. 2001;286:415–20.

    Article  PubMed  CAS  Google Scholar 

  20. Leape LL, Brennan TA, Laird N, et al. The nature of adverse events in hospitalized patients: results of the Harvard Medical Practice Study II. N Engl J Med. 1991;324:377–84.

    PubMed  CAS  Google Scholar 

  21. Fisher ES, Welch HG. Is this issue a mistake? Eff Clin Pract. 2000;3:290–3.

    PubMed  CAS  Google Scholar 

  22. Hofer TP, Hayward RA. Are bad outcomes from questionable clinical decisions preventable medical errors?: a case of cascade iatrogenesis. Ann Intern Med. 2002;137:327–33.

    PubMed  Google Scholar 

  23. Hofer TP, Kerr EA, Hayward RA. What is an error? Eff Clin Pract. 2000;3:261–9.

    PubMed  CAS  Google Scholar 

  24. Caplan RA, Posner KL, Cheney FW. Effect of outcome on physician judgments of appropriateness of care. JAMA. 1991;265:1957–60.

    Article  PubMed  CAS  Google Scholar 

  25. Thompson SC, Armstrong W, Thomas C. Illusions of control, underestimations, and accuracy: a control heuristic explanation. Psychol Bull. 1998;123:143–61.

    Article  PubMed  CAS  Google Scholar 

  26. Hofer TP, Asch SM, Hayward RA, et al. Profiling quality of care: is there a role for peer review? BMC Health Serv Res. 2004;4:9.

    Article  PubMed  Google Scholar 

  27. Goldman RL. The reliability of peer assessments of quality of care. JAMA. 1992;267:958–60.

    Article  PubMed  CAS  Google Scholar 

  28. Dovey SM, Meyers DS, Phillips RL Jr, et al. A preliminary taxonomy of medical errors in family practice. Qual Safety Health Care. 2002;11:233–8.

    Article  CAS  Google Scholar 

  29. Bates DW, Cullen DJ, Laird N, et al. Incidence of adverse drug events and potential adverse drug events. Implications for prevention. ADE prevention study group. JAMA. 1995;274:29–34.

    Article  PubMed  CAS  Google Scholar 

  30. Elder NC, Dovey SM. Classification of medical errors and preventable adverse events in primary care: a synthesis of the literature. J Fam Pract. 2002;51:927–32.

    PubMed  Google Scholar 

  31. McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. N Engl J Med. 2003;348:2635–45.

    Article  PubMed  Google Scholar 

  32. Hofer TP, Bernstein SJ, DeMonner S, Hayward RA. Discussion between reviewers does not improve reliability of peer review of hospital quality. Med Care. 2000;38:152–61.

    Article  PubMed  CAS  Google Scholar 

  33. Kent DM, Hayward RA, Griffith JL, et al. An independently derived and validated predictive model for selecting patients with myocardial infarction who are likely to benefit from tissue plasminogen activator compared with streptokinase. Am J Med. 2002;113:104–11.

    Article  PubMed  CAS  Google Scholar 

  34. Hayward RA. Diabetes care priorities: preventing cardiovascular complications. Pract Matters. 2000;5:1–6.

    Google Scholar 

  35. Brook RH. Appropriateness: the next frontier. BMJ. 1994;308:218–9.

    PubMed  CAS  Google Scholar 

  36. Glasgow RE, Hiss RG, Anderson RM, et al. Report of the health care delivery work group: behavioral research related to the establishment of a chronic disease model for diabetes care. Diabetes Care. 2001;24:124–30.

    Article  PubMed  CAS  Google Scholar 

  37. Wenger NS, Solomon DH, Roth CP, et al. The quality of medical care provided to vulnerable community-dwelling older patients. Ann Intern Med. 2003 Nov 4;139:740–7.

    PubMed  Google Scholar 

  38. Brennan TA. The Institute of Medicine Report on medical errors — could it do harm? N Engl J Med. 2000;342:1123–5.

    Article  PubMed  CAS  Google Scholar 

  39. Jha AK, Perlin JB, Kizer KW, Dudley RA. Effect of the transformation of the Veterans Affairs Health Care System on the quality of care. N Engl J Med. 2003;348:2218–27.

    Article  PubMed  Google Scholar 

  40. Asch SM, McGlynn EA, Hogan MM, et al. Comparison of quality of care for patients in the Veterans Health Administration and patients in a national sample. Ann Intern Med. 2004;141:938–45.

    PubMed  Google Scholar 

  41. Kerr EA, Gerzoff RB, Krein SL, et al. A comparison of diabetes care quality in VA and commercial managed care: the TRIAD study. Ann Intern Med. 2004;141:272–81.

    PubMed  Google Scholar 

  42. O’Neil AC, Petersen LA, Cook EF, Bates DW, Lee TH, Brennan TA. Physician reporting compared with medical-record review to identify adverse medical events. Ann Intern Med. 1993;119:370–6.

    PubMed  CAS  Google Scholar 

  43. Bates DW, Leape LL, Petrycki S. Incidence and preventability of adverse drug events in hospitalized adults. J Gen Intern Med. 1993;8:289–94.

    Article  PubMed  CAS  Google Scholar 

  44. Brennan TA, Localio AR, Leape LL, et al. Identification of adverse events occurring during hospitalization. A cross-sectional study of litigation, quality assurance, and medical records at two teaching hospitals. Ann Intern Med. 1990;112:221–6.

    PubMed  CAS  Google Scholar 

  45. Luck J, Peabody JW, Dresselhaus TR, Lee M, Glassman P. How well does chart abstraction measure quality? A prospective comparison of standardized patients with the medical record. Am J Med. 2000;108:642–9.

    Article  PubMed  CAS  Google Scholar 

  46. Donabedian A. Quality, cost: choices and responsibilities. Inquiry. 1988;25:90–9.

    PubMed  CAS  Google Scholar 

  47. Donabedian A. The Definition of Quality and Approaches to its Assessment. Ann Arbor, Mich: Health Administration Press; 1980.

    Google Scholar 

  48. Woolf SH. Patient safety is not enough: targeting quality improvements to optimize the health of the population. Ann Intern Med. 2004;140:33–6.

    PubMed  Google Scholar 

  49. Reason J. Human error: models and management. BMJ. 2000;320:768–70.

    Article  PubMed  CAS  Google Scholar 

  50. Reason JT. Managing the Risks of Organizational Accidents. Burlington, Vt: Ashgate Publishing.

  51. Perrow C. Normal Accidents Living with High-risk Technologies. 2nd ed. Princeton, NJ: Princeton University Press; 1999.

    Google Scholar 

  52. Something must (not) be done. The Economist. September 11, 2003

  53. Vijan S, Hayward RA. Treatment of hypertension in type 2 diabetes mellitus: blood pressure goals, choice of agents, and setting priorities in diabetes care. Ann Intern Med. 2003;138:593–602.

    PubMed  Google Scholar 

  54. Rosen AB, Karter AJ, Liu JY, Selby JV, Schneider EC. Use of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers in high-risk clinical and ethnic groups with diabetes. J Gen Int Med. 2004;19:669–75.

    Article  Google Scholar 

  55. Yarnall KS, Pollak KI, Ostbye T, Krause KM, Michener JL. Primary care: is there enough time for prevention? Am J Public Health. 2003;93:635–41.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Rodney A. Hayward MD.

Additional information

The work was supported by the Department of Veterans Affairs Health Services Research & Development (HSR&D) Grant IIR 98–103, with additional support from the VA Quality Enhancement Research Initiative (HSR&D DIB #98-001) and the Michigan Diabetes Research & Training Center (NIDDK P60-972573). Drs. Kerr and Asch were supported by Career Development Awards from the HSR&D Office of the Department of Veterans Affairs.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Hayward, R.A., Asch, S.M., Hogan, M.M. et al. Sins of omission. J Gen Intern Med 20, 686–691 (2005). https://doi.org/10.1111/j.1525-1497.2005.0152.x

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Issue Date:

  • DOI: https://doi.org/10.1111/j.1525-1497.2005.0152.x

Key words

Navigation