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AHRQ study: Teamwork breakdowns lead to medical errors

Quality Improvement Monitor, October 26, 2007

Physicians-in-training are at risk of making medical errors because of teamwork breakdowns, especially a lack of supervision by experienced staff, according to a new study funded by the Agency for Healthcare Research and Quality (AHRQ).

Teamwork snafus also caused a significant number of errors to occur during patient handoffs, researchers found. The study, Medical Errors Involving Trainees: A Study of Closed Malpractice Claims from 5 Insurers, appears in the October 22, 2007 Archives of Internal Medicine, according to a press release from AHRQ.

The study, conducted by researchers at the Michael E. DeBakey Veterans Affairs Medical Center,the Baylor College of Medicine, the University of Texas Medical School at Houston, and the Harvard School of Public Health, looked at data from nearly 900 closed malpractice claims.

Of those claims in which there were both error and injury, 27% involved trainees whose role in the error was considered to be at least moderately important, the study found. Medical residents were involved in 87% of those cases; interns and fellows each were participants in 13%. Adverse outcomes were serious: one-third resulted in significant physical injury, one-fifth in major physical injury, and one-third resulted in death. Almost a third of the cases took place in the outpatient setting.

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