Research ArticleOriginal Research

A String of Mistakes: The Importance of Cascade Analysis in Describing, Counting, and Preventing Medical Errors

Steven H. Woolf, Anton J. Kuzel, Susan M. Dovey and Robert L. Phillips
The Annals of Family Medicine July 2004, 2 (4) 317-326; DOI: https://doi.org/10.1370/afm.126

Article Figures & Data

Figures

  • Figure 1.
    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.

  • Figure 2.
    Figure 2.

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

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

  • Figure 3.
    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.

  • Figure 4.
    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.

  • Figure 5.
    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.

Tables

  • Table 1.

    Characteristics of Error Reports (N = 75)

    CharacteristicsNo. (%)
    Error related to an individual patient73 (97)
    Patient characteristics
    Age: Less than 18 years8 (11)
        18–64 years38 (52)
        Above 64 years21 (29)
    Gender (male/female)26/44 (37/63)
    Racial/ethnic minority19 (26)
    Chronic health condition44 (60)
    Complex health condition34 (47)
    Physician familiarity with patient
        Very familiar with the patient and their health condition(s)28 (38)
        Never seen the patient before and unfamiliar7 (23)
    Sites of care implicated in reported error
    Physician’s office52 (69)
    Hospital16 (21)
    Laboratory5 (7)
    Pharmacy5 (7)
    Telephone contact4 (5)
    Emergency room3 (4)
    Nursing home2 (3)
    Patient’s home2 (3)
    Radiology2 (3)
    Another place2 (3)

Additional Files

  • Supplemental Appendix

    Expanded Study Details.

    Files in this Data Supplement:

  • The Article in Brief

    Studying medical errors as a chain of events can shed light on the underlying causes of the errors. Using this approach, the authors found that, in primary care offices in 6 different countries, 2 out of 3 chains of medical errors were set in motion by errors in communication. This suggests that communication issues should be considered in programs to reduce medical errors.

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