Two-Year Profile of Preventable Errors in Hospital-Based Neurology

摘要

Background and Objectives Medical errors are estimated to cause 7,000 deaths and cost 17-29 billion USD per year, but there is a lack of published real-world data on preventable errors, in particular in hospital-based neurology. We sought to characterize the profile of errors that occur on the inpatient neurology services at our institution to inform strategies on future error prevention. Methods We reviewed all cases of preventable errors occurring on the inpatient neurology services from July 1, 2018, to June 30, 2020, logged in institutional error reporting systems and reviewed at departmental morbidity and mortality conferences (M&MC). Each case was characterized by primary category of error, level of harm as determined by the Agency for Healthcare Research & Quality Common Format Harm Scale version 1.2, primary intervention, and recurrence within 1 year, with a final censoring date of June 30, 2021. Results Of 72 cases, 43 (60%) were attributed to errors in clinical decision making and 20 (28%) to systems or electronic health record-related errors. The majority of cases resulted in in-conference education on systems-based errors (29%) at departmental M&MCs followed by in-conference education on clinical neurology (25%). Among errors classified primarily as clinical, 28% were addressed via systems-based interventions including in-conference education on systems issues and changes in written protocol. In 23 cases (32%), a similar error recurred within 1 year of the presentation. In total, 7 cases (10%) resulted in a change in written protocol, none with recurrences. Discussion Systems-based interventions may reduce both clinical and systems-based errors, and protocol changes are effective when feasible. Given the important goal of optimizing care for every patient, quality leaders should conduct continuous audits of preventable errors and quality improvement systems in their clinical areas.