Clinical Chemistry
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

Clinical Chemistry 52: 2120-a, 2006; 10.1373/clinchem.2006.077933
This Article
Right arrow Extract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Krouwer, J. S.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Krouwer, J. S.
Related Collections
Right arrow Laboratory Management
(Clinical Chemistry. 2006;52:2120.)
© 2006 American Association for Clinical Chemistry, Inc.

Letters to the Editor

More on Reporting Medical Errors

Jan S. Krouwer

Krouwer Consulting, 26 Parks Drive, Sherborn, MA, Fax 508-647-9380, E-mail jan.krouwer{at}comcast.net


To the Editor:

Crone et al. (1) present a case study with much of their discussion about aspects of reporting suspected medical errors, particularly when there is a possibility of misconduct or violation of rules. Marx (2), who described a useful taxonomy of medical errors, recommends that no blame be given except for certain situations, one of which can be summarized as "failure to report safety incidents or risk exposures".

In the clinical laboratory case discussion of Crone et al. (1), the fact that the risk management team decided later that no error had occurred would not excuse a person from reporting an event thought to be an error. As described in the case report, it was up to the (risk management) team to classify the severity of reported events, including the classification that no error occurred.

In discussing error reduction, Cone et al. focus on root cause analysis of sentinel events, omitting discussion of FMEA (Failure Mode Effects Analysis), which is designed to decrease the risk of potential errors. A successful FMEA will lead to fewer (and possibly no) sentinel events. FRACAS (Failure Review and Corrective Action System) is a tool to decrease the recurrence of observed events. In contrast to other industries, hospitals typically subject only sentinel events to root cause analysis. In a FRACAS, all errors are counted, and corrective actions are taken on those with the highest severity and frequency of occurrence. The process has a quantitative goal of reducing the combined error rate to an acceptable number, and the FRACAS process measures the combined error rate on a regular basis.


References

  1. Crone KG, Muraski MB, Skeel JD, Love-Gregory L, Ladenson JH, Gronowski AM. Between a rock and a hard place: disclosing medical errors. Clin Chem 2006;52:1809-1814.[Abstract/Free Full Text]
  2. Marx D. Patient safety and the "just culture": a primer for health care executives. Medical Event Reporting System for Transfusion Medicine 2001. Available at: http://www.mers-tm.net/support/Marx_Primer.pdf (accessed July 22, 2006)..




This Article
Right arrow Extract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Krouwer, J. S.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Krouwer, J. S.
Related Collections
Right arrow Laboratory Management

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS