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Annals of Family Medicine 2:317-326 (2004)
© 2004 Annals of Family Medicine, Inc.
doi: 10.1370/afm.126
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A String of Mistakes: The Importance of Cascade Analysis in Describing, Counting, and Preventing Medical Errors

Steven H. Woolf, MD, MPH1, Anton J. Kuzel, MD, MHPE1, Susan M. Dovey, MPH, PhD2 and Robert L. Phillips, Jr, MD, MSPH2

1 Department of Family Medicine, Virginia Commonwealth University, Richmond, Va
2 Robert Graham Center: Policy Studies in Family Practice and Primary Care, American Academy of Family Physicians, Washington, DC



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  		Figure 1. Examples of cascade of errors revealed in physicians’ descriptions of incidents.

Treatment (TR) = errors in administering treatments, medications, immunizations, and care plans; diagnosis (DX) = errors in screening, diagnostic examination and testing, and interpretation of findings; informational communication (IC) = errors in processing messages, instructions, and medical record data; personal communication (PC) = errors in interpersonal communication among providers and patients; CBC = complete blood count.

 


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  		Figure 2. Errors precipitating the 45 distal errors in treatment described in the narratives.

Note: Errors in communication (shaded) predominate throughout the causal chain.

 


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  		Figure 3. Distribution across 5 domains of care for all errors (N = 184) reported in 75 incidents and for proximal (first or underlying) and distal (final or ultimate) errors at either end of the cascades (N = 83 and 84, respectively).

Note: Distal errors predominantly involve treatment, but communication errors predominate at the outset. Treatment = errors in administering treatments, medications, immunizations, and care plans; diagnosis = errors in screening, diagnostic examination and testing, and interpretation of findings; informational communication (IC) = errors in processing messages, instructions, and medical record data; personal communication (PC) = errors in interpersonal communication among providers and patients.

 


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  		Figure 4. Consequences to patients as reported by physicians and inferred by investigators.

Note: Physicians were more likely to report physical harms and less likely to report emotional or psychological effects.

 


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  		Figure 5. Analytic construct to incorporate Reason’s model of organizational accidents into the notion of cascades.

Note: The construct recognizes that each error in the cascade can arise from error-producing conditions, which exist because of latent failures, and that the errors occur in the absence of adequate defenses (safeguards). The predisposing factors that contribute to each error are not necessarily distinct, eg, fatigue may cause error A and error B, nor does injury only occur as a result of distal errors.

 




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