Prospectively Recording Errors Is Valuable in Reducing Complications

Caroline Gunaratnam¹, Adetunji Adeniyi Oremakinde², Mark Bernstein¹

¹Division of Neurosurgery and Joint Center for Bioethics, University Health Network, Toronto, Canada.
²Department of Neurological Surgery, University College Hospital, Ibadan, Nigeria.

DOI: 10.4236/health.2014.618274                

Abstract

Errors have traditionally been a less commonly discussed topic but are becoming increasingly examined due to a trend towards expanded awareness about the high human and financial cost of errors in medicine. Recording and reporting of errors has been a difficult issue in the health sector due to fear of litigation from patients, complaint to governing bodies, and embarrassment from colleagues. In this article we examine the advantages of prospective error recording. The studies on this subject report that the culture of prospective error recording is of high value in improving most parameters of errors and may indeed reduce complications.

Keywords

Prospective Study, Error Recording, Prevention, Neurosurgery, Prospective Value

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1]	Gawande, A. (1999) When Doctors Make Mistakes. The New Yorker, 1, 40-55.
[2]	Brennan, T.A., Leape, L.L., Laird, N.M., et al. (1991) Incidence of Adverse Events and Negligence in Hospitalized Patients: Results of the Harvard Medical Practice Study I. New England Journal of Medicine, 324, 370-376. http://dx.doi.org/10.1056/NEJM199102073240604
[3]	Gawande, A.A., Thomas, E.J., Zinner, M.J., et al. (1999) The Incidence and Nature of Surgical Adverse Events in Colorado and Utah in 1992. Surgery, 126, 66-75. http://dx.doi.org/10.1067/msy.1999.98664
[4]	Leape, L.L., Brennan, T.A., Laird, N., et al. (1991) The Nature of Adverse Events in Hospitalized Patients: Results of the Harvard Medical Practice Study II. New England Journal of Medicine, 324, 277-384. http://dx.doi.org/10.1056/NEJM199102073240605
[5]	Vincent, C., Neale, G. and Woloshynowych, M. (2001) Adverse Events in British Hospitals: Preliminary Retrospective Record Review. BMJ, 322, 517-519. http://dx.doi.org/10.1136/bmj.322.7285.517
[6]	Wilson, R.M., Harrison, B.T., Gibberd, R.W., et al. (1999) An Analysis of the Causes of Adverse Events from the Quality of Australian Health Care Study. Medical Journal of Australia, 170, 411-415.
[7]	Stone, S. and Bernstein, M. (2007) Prospective Error Recording in Surgery: An Analysis of 1108 Elective Neurosurgical Cases. Neurosurgery, 60, 1075-1082.
[8]	Etchells, E., O’Neill, C. and Bernstein, M. (2003) Patient Safety in Surgery: Error Detection and Prevention. World Journal of Surgery, 27, 936-942. http://dx.doi.org/10.1007/s00268-003-7097-2
[9]	Kohn, L.T., Corrigan, J.M. and Donaldson, M.S. (2000) Errors in Health Care: A Leading Cause of Death and Injury. In: To Err Is Human: Building a Sager Health System, National Academy Press, Washington DC, 26-48.
[10]	Bostrom, J., Yacoub, A. and Schramm, J. (2010) Prospective Collection and Analysis of Error Data in a Neurosurgical Clinic. Clinical Neurology and Neurosurgery, 112, 314-319. http://dx.doi.org/10.1016/j.clineuro.2010.01.001
[11]	Oremakinde, A.A. and Bernstein, M. (2014) A Reduction in Errors Is Associated with Prospectively Recording Them. Journal of Neurosurgery, 121, 297-304. http://dx.doi.org/10.3171/2014.5.JNS132341
[12]	Bosma, E., Veen, E.J. and Roukema, J.A. (2011) Incidence, Nature and Impact of Error in Surgery. British Journal of Surgery, 98, 1654-1659. http://dx.doi.org/10.1002/bjs.7594
[13]	Cohen, F.L., Mendelsohn, D. and Bernstein, M. (2010) Wrong-Site Craniotomy: Analysis of 35 Cases and Systems for Prevention. Journal of Neurosurgery, 113, 461-473. http://dx.doi.org/10.3171/2009.10.JNS091282
[14]	Rebasa, P., Mora, L., Luna, A., Montmany, S., Vallverdú, H. and Havarro, S. (2009) Continuous Monitoring of Adverse Events: Influence on the Quality of Care and the Incidence of Errors in General Surgery. World Journal of Surgery, 33, 191-198. http://dx.doi.org/10.1007/s00268-008-9848-6
[15]	Bernstein, M. (2003) Wrong-Side Surgery: Systems for Prevention. Canadian Journal of Surgery, 46, 144-146.
[16]	Holliman, D. and Bernstein, M. (2012) Patients’ Perception of Error during Craniotomy for Brain Tumor and Their Attitudes towards Pre-Operative Discussion of Error: A Qualitative Study. British Journal of Neurosurgery, 26, 236-330. http://dx.doi.org/10.3109/02688697.2011.633642