Julia is a 5th year medical student at the University of Auckland. Prior to this I completed a Bachelor of Science Majoring in Neuroscience at The University of Otago. I have an interest in research and this project was undertaken alongside Dr Laura Chapman who was my supervisor for my year 5 selective placement which I chose to complete in general medicine at Waitemata DHB.
Medical Error: Under-Represented in CME, Over-Represented in Mortality Statistics?
To assess opportunities for qualified physicians to learn about error through CME events.
Medical error is the third leading cause of death (1). Definitions centre on preventable adverse effects of patient care (2). Error reduction is difficult due to stigma, health system complexities (1) and disparities in teaching and understanding (3,4). Morbidity and mortality (M+M) and quality and safety (Q+S) processes also concern medical error (5).
A retrospective review of 15 publicly available 2016-19 conference programmes across 5 medical specialties was performed. Purposeful sampling was undertaken to ensure inclusion of a broad range of conferences addressing Australian/NZ medical practice. Each programme was analysed for presentations addressing medical error, M+M and Q+S, hours of teaching and variation by speciality.
‘Medical error’ was defined as clinical reasoning, clinician cognition, cognitive bias, human factors and teamwork.
2/15 conferences addressed medical error. Two further conferences addressed M+M and/or Q+S. 1%(2.5/377) CME hours focussed on error rising to 2%(4/377) with inclusion M+M and/or Q+S .
Error is the third leading cause of patient death but occupied <2% of available CME hours on offer and was only discussed at 4/15 conferences. The lack of focus on this important issue may reflect poor awareness, disinterest and/or lack of ownership of the problem by clinicians. The paucity of error-focussed education is surprising given the extent of the problem.
Include study size, potential nomenclature issues leading to under-identification of sessions and overestimation of percentage time on error due to concurrent sessions.
Medical conferences are an opportunity to raise awareness and seek solutions. The sparsity of CME on medical error is a lost opportunity to improve patient care and likely to contribute to ongoing error.
1. Makary M, Daniel M. Medical error—the third leading cause of death in the US. BMJ. 2016;353:2139.
2. Kohn, L.T., Corrigan, J.M. & Donaldson, M.S. (eds.) (2000). To Err Is Human: Building a Safer Health System. Institute of Medicine (IOM). Washington, D.C: National Academy Press
3. Donaldson, L. (ed) (1999) An Organisation with a Memory: report of an expert group on learning from adverse events in the NHS chaired by the Chief Medical Officer. Department of Health. London, UK, The Stationery Office
4. Leape LL. Error in medicine. JAMA 1994;272:1851-7. doi:10.1001/jama.1994. 03520230061039 pmid:7503827
5. Ghaferi A, Birkmeyer J, Dimick J. Complications, Failure to Rescue, and Mortality With Major Inpatient Surgery in Medicare Patients. Annals of Surgery. 2009;250(6):1029-1034.