Policy Research
Information Technology
Malpractice and Error Reporting
Staffing and System-Level Issues
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For more information and resources on information technology, go to the Health Information Technology Issue Module.
Caudill-Slosberg M and WB Weeks. 2005. Case Study: Identifying Potential Problems at the Human/Technical Interface in Complex. American Journal of Medical Quality 20(6):353–357.
In this paper, two researchers use a case study to explain possible vulnerabilities in the use of new technology such as computerized physician orders or electronic medical records.
Cutler DM, NE Feldman, and JR Horowitz. 2005. U.S. Adoption Of Computerized Physician Order Entry Systems. Health Affairs 24(6):1654–1663.
Computerized physician order entry (CPOE) systems could potentially reduce medical errors, however implementation rates have been low. This article empirically examines possible explanations to implementation rates of CPOE systems in hospitals, focusing on hospital ownership, teaching status, profitability, and the reimbursement system.
Garg AX, NKJ Adhikari, H McDonald, et al. Mar 2005. Effects of Computerized Clinical Decision Support Systems on Practitioner Performance and Patient Outcomes. Journal of the American Medical Association 293(10):1223–1238.
Based on a review of 100 primary studies, this paper reviews trials of the computerized clinical decision support system (CDSS). It discusses the impact of CDSS use on patient outcomes and practitioner performance when used in diagnosis, reminder, disease management, and prescribing systems.
Hillestad R, J Bigelow, A Bower, et al. 2005. Can Electronic Medical Record Systems Transform Health Care? Potential Health Benefits, Savings, and Costs. Health Affairs 24(5):1103–1117.
Based on comparisons to savings and losses in other industries after the implementation of electronic records, this paper estimates financial impacts of electronic medical records with respect to medical safety and health management.
Koppel R, JP Metlay, A Cohen, et al. Mar 2005. Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors. Journal of the American Medical Association 293(10):1197–1203.
Based on a two-year observational and interview study of hospital staff using a CPOE system, this paper discusses the medical errors potentially prevented and also raised by CPOE systems.
Moore GT, Robert Wood Johnson Foundation. Sept 2006. Information Technology and Primary Care.
This white paper summarizes a meeting of information technology and practice systems experts to explore how information technology might contribute to an optimized model of primary care to transform the delivery of patient care.
Nebeker JR, JM Hoffman, CR Weir, et al. May 2005. High Rates of Adverse Drug Events in a Highly Computerized Hospital. Archives of Internal Medicine 165(10):1111–1116.
Based on analysis of hospital’s records, this paper assesses the impact of using electronic medical records on the likelihood of adverse drug events.
Shulman R, M Singer, J Goldstone, et al. April 2005. Medication Errors: A Prospective Cohort Study of Hand-Written and Computerized Physician Order Entry in the Intensive Care Unit. Critical Care 9:R516–R521.
Based on a study of London physicians that used a computerized physician order entry (CPOE) system and those who did not use CPOE for prescribing, this paper compares the outcomes and medical errors rate.
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Bovbjerg RR and LR Tancredi. 2005. Liability Reform Should Make Patients Safer: “Avoidable Classes of Events” Are A Key Improvement. Journal of Law Medical Ethics 33:478–500.
This commentary discusses patient compensation after medical errors, exploring potential no-blame culture and malpractice reform that could impact the way medical errors are reported and managed.
Brennan T and M Mello. August 2003. Patient Safety and Medical Malpractice: A Case Study. Annals of Internal Medicine 139:267–273.
The authors explore the malpractice debate through the lens of patient safety by profiling a medical case. They propose changes in current dispute resolution practices and the possible effects on patient safety and quality of care.
Case Manager Staff. May-Jun 2005. Case Managers’ Encounters with Errors, The Case Manager.
Using anecdotes from real experiences, this article illustrates difficulties that case managers face in suspecting, identifying, classifying, and reporting medical errors.
Gallagher TH, D Studdert and W Levinson. Jun 2007. Disclosing Harmful Medical Errors to Patients. New England Journal of Medicine 356(26):2713-19.
This article discusses disclosure standards, legal developments concerning disclosure and program initiatives aimed at improving disclosure.
Marchey M, National Academy of State Health Policy. Dec 2003. Medical Malpractice and Medical Error Disclosure: Balancing Facts and Fears.
This brief addresses the issues raised by the convergence of medical error reporting and the fear of medical malpractice litigation. It discusses how states protect data with the intention of increasing the compliance level of reporting, examines a sample state protection statute, and explores proposals for alternatives to address the fear of possible malpractice litigation.
Marchey M, J Rosenthal, and M Booth, National Academy for State Health Policy. Oct 2003. How States Report Medical Errors to the Public: Issues and Barriers.
This report addresses issues pertaining to the protection and disclosure of data in state mandatory reporting systems, including when and how states disclose data and the perceived relationship between reporting and medical malpractice litigation. The report is based upon detailed interviews with states with mandatory reporting requirements.
Mello M, Council on Health Care Economics and Policy. Mar 2003. Malpractice Liability and Medical Error Prevention: Strange Bedfellows?.
This paper explores the relationship between tort law and patient safety. Three issues are discussed: the strength of the evidence that tort law improves medical quality, the impacts of tort law on patient safety, and policy reforms to improve the interface between the medical liability system and the individual and institutional providers.
Mello M and D Hemenway. July 2004. Medical Malpractice as an Epidemiological Problem. Social Science & Medicine 59(1):39–46.
Using a familiar analogy from epidemiology—the problem of false positives in screening tests for rare diseases—and data from two large studies of medical injuries and malpractice claims in the United States, this paper presents an argument that the standard interpretation overlooks a complexity in the data on medical malpractice lawsuits.
Mello M, Robert Wood Johnson Foundation. Jan 2006. Understanding Medical Malpractice Insurance: A Primer.
This primer discusses the issues of malpractice insurance and analyzes the causes of and potential solutions to address malpractice crises.
Rosenthal J and M Booth, National Academy for State Health Policy. Mar 2003. Defining Reportable Adverse Events: A Guide for States Tracking Medical Errors.
This report was developed to help policy makers develop, refine, and clarify mandatory reporting systems and potentially to compare their data nationally. The guide includes a crosswalk that compares the National Quality Forum’s (NQF) list of serious reportable events to existing state reporting systems and discusses further steps recommended by states to support the use and consistent implementation of the NQF list.
Roumm AR, CN Sciamanna, and DB Nash. 2005. Health Care Provider Use of Private Sector Internal Error-Reporting Systems. American Journal of Medical Quality 20(6):304–312.
This study examines the design of nine different private sector internal error-reporting systems, focusing on the system’s relationship to other hospitals and ability to interface with other systems.
Weissman JS, CL Annas, AM Epstein, et al. Mar 2005. Error Reporting and Disclosure Systems. Journal of the American Medical Association 293(11):1359–1366.
This article examines the opinions and experiences of hospital leaders in states with medical errors reporting mandates.
Wood KE and DB Nash. 2005. Mandatory State-Based Error-Reporting Systems: Current and Future Prospects. American Journal of Medical Quality 20(6):297–303.
Based on a review of current systems for error reporting in states with mandatory reporting policies, this paper poses challenges and potential areas for expansion.
Zivin JG and ASP Pfaff. Sept 2004. To Err On Humans Is Not Benign: Incentives for Adoption of Medical Error-Reporting Systems. Journal of Health Economics 23(5):935–949.
In this policy paper, authors suggest an alternative malpractice system to reduce medical errors and increase rates of compliant medical reporting.
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Berwick DM, DR Calkins, J McCannon, et al. Jan 2006. The 100 000 Lives Campaign: Setting a Goal and a Deadline for Improving Health Care Quality. Journal of the American Medical Association 295:324–327.
This paper recommends and outlines six ways that hospitals and providers can reduce medical errors. It also summarizes the 100,000 Lives Campaign, which is a national initiative launched in December 2004 to save 100,000 lives through improving safety and reducing medical errors.
Brennan TA, A Gawande, E Thomas, et al. Sept 2005. Accidental Deaths, Saved Lives, and Improved Quality. New England Journal of Medicine 353:1405–1409.
In this article, authors discuss challenges with measuring quality of care while suggesting ways to improve how quality is measured.
France DJ, P Throop, B Walczyk, et al. Sept 2005. Does Patient-Centered Design Guarantee Patient Safety?: Using Human Factors Engineering to Find a Balance Between Provider and Patient Needs. Journal of Patient Safety 1(3):145–153.
Based on surveys of 270 clinical staff, this study provides early impressions of a patient-centric hospital design and the design’s impact on patient safety and quality of care.
Gandhi TK, E Graydon-Baker, H Neppl, et al. Nov 2005. Closing the Loop: Follow-Up and Feedback in a Patient Safety Program. Joint Commission Journal on Quality and Patient Safety 31(11):614–621.
This research article discusses feedback components for medical errors reporting systems.
Gauthier A and M Serber, The Commonwealth Fund. Oct 2005. A Need to Transform the U.S. Health Care System: Improving Access, Quality, and Efficiency.
Reviewing studies and data on quality along several measures, this analysis compares quality of care in the U.S. to other countries and points out key differences in the respective health systems.
Hughes RG and CM Clancy. Oct–Dec 2005. Working Conditions that Support Patient Safety Agency for Healthcare Research and Quality. Journal of Nursing Care Quality 20(4):289–292.
Based on data by the Agency for Healthcare Research and Quality, this paper reviews staffing and cultural factors that affect patient safety.
Landrigan CP, JM Rothschild, JW Cronin, et al. 2004. Effect of Reducing Interns’ Work Hours on Serious Medical Errors in Intensive Care Units. New England Journal of Medicine 351:1838–1848.
Using a random sampling of interns in intensive care units, this study analyzed rate of major medical errors and length of intern work shifts.
Rosenfeld S, E Zeitler, and D Mendelson, Health Strategies Consultancy and Foundation for eHealth Initiative, Leapfrog Group. Mar 2004. Financial Incentives: Innovative Payment for Health Information Technology.
This report discusses designs for incentive programs to improve quality of care.
Rotherberg MB, I Abraham, PK Lindenauer, et al. 2005. Improving nurse-to-patient staffing ratios as cost-effective safety intervention. Medical Care 43(8):785–791.
Based on a cost-effectiveness analysis, this study examined patient-to-nurse ratios and mortality rates. It estimates the least and most effective ratios for maximizing patient safety.
U.S. Food and Drug Administration. Jan 2006. FDA Announces New Prescription Drug Information Format to Improve Patient Safety.
This press release gives an overview of the FDA's revised guidelines, which oversee the format of the prescription inserts that doctors use to learn about prescription drug indications. The press release also provides links to full-text versions of the guidelines, as well as information about errors in prescribing.
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