Full text of DOI:10.1111/j.1553-2712.2000.tb00482.x

ACADEMIC EMERGENCY MEDICINE • November 2000, Volume 7, Number 11
1317
Emergency Medicine Resident Errors:
Identification and Educational Utilization
CHERRI D. HOBGOOD, MD, O. JOHN MA, MD, GARY L. SWART, MD
Abstract. Objectives: To evaluate the error man- ment audits (60%). A majority of programs (58%)
agement systems emergency medicine residency di- present resident cases anonymously in order to en-
rectors (EMRDs) use to identify and report clinical hance teaching (39%), to avoid embarrassment (28%),
errors made by emergency medicine residents and and to avoid individual blame (24%). While mandated
their satisfaction with error-based teaching as an ed- resident remediation is not required at 48% of the
ucational tool. Methods: All 112 EMRDs listed by the programs, 24% require lectures, 17% require written
Accreditation Council for Graduate Medical Educa- reports, and 6% require extra clinical shifts. The
tion in 1996 were sent a 15-item survey. Five areas EMRDs rated the educational value of morbidity and
of error evaluation and management were assessed: mortality conference as outstanding (11%) or excel-
1) systems for tracking and reporting clinical errors; lent (53%), and rated their systems for identifying
2) resident participation in the systems; 3) resident key resident errors as outstanding (0%), excellent
remediation; 4) EMRD-perceived satisfaction with (14%), or good (47%). Conclusions: All emergency
current error-reporting mechanisms, their educa- medicine residency programs have systems to track
tional value, and their ability to identify and prevent and report resident errors. Resident participation
errors; and 5) EMRDs’ perceptions of faculty and res- varies widely, as does resident remediation processes.
ident satisfaction with the systems. Results: The re- Most EMRDs are satisfied with their systems but few
sponse rate was 86%. All EMRDs indicated that EMRDs rate them as excellent in the detection or
methods are in place to track and report errors at prevention of clinical errors. Key words: education;
their institutions. These include morbidity and mor- quality assurance; clinical operations. ACADEMIC
tality conference (94%), quality assurance case review EMERGENCY MEDICINE 2000; 7:1317–1320
conference (76%), and continuous quality improve-
LINICAL error in medical practice is a well- a source of emotional distress as well as learning
opportunities.10 Resident errors provide skillful
C
recognized phenomenon. Previous studies of
inpatient services in major teaching hospitals sug-
gest that 3.7% to 38% of hospitalized patients suf-
fer from an adverse iatrogenic event or illness.1–3
Many of these iatrogenic events were caused by
preventable errors.1,2 Although much has been
written on errors in medicine,1–17 most studies
have focused on adverse patient outcomes,1–5 in-
creased medical cost,6,7 and the legal implications
of such error.8 Little attention has focused specifi-
cally on resident error educational systems.9 For
resident physicians in training, errors can become
medical educators with a unique teaching tool;
however, little is know about how these errors are
used in an educational format. To the best of our
knowledge, no previous study has investigated
how emergency medicine (EM) residency programs
track and report clinical errors made by their res-
idents.
The objective of this study was to determine
how error management systems varied between
EM residency programs and to what degree EM
residency directors (EMRDs) were satisfied with
their systems’ performance.
From the Department of Emergency Medicine, University of
North Carolina School of Medicine, Chapel Hill, NC (CDH,
OJM); Department of Emergency Medicine, Truman Medical
Center, University of Missouri–Kansas City School of Medi-
cine, Kansas City, MO (OJM current affiliation); and Depart-
ment of Emergency Medicine, Medical College of Wisconsin,
Milwaukee, WI (GLS).
Received November 29, 1999; revision received February 18,
2000; accepted February 21, 2000. Presented at the American
College of Emergency Physicians Research Forum, San Fran-
cisco, CA, October 1997.
Address for correspondence and reprints: Cherri D. Hobgood,
MD, Department of Emergency Medicine, University of North
Carolina School of Medicine, CB #7594, Ground Floor, Neuro-
sciences Building, Chapel Hill, NC 27599-7594. Fax: 919-966-
3049; e-mail: hobgood@med.unc.edu
M
ETHODS
Study Design. The survey instrument was de-
veloped by the investigators to assess five areas of
EM resident clinical error management. Prototype
surveys were used to refine questions. The 15-item
survey was sent to all EMRDs (available on re-
quest). The medical center’s institutional review
board approved the study protocol.
Study Setting and Population. All 112 EMRDs
listed by the Accreditation Council for Graduate
Medical Education in 1996 were enlisted to partic-

1318
RESIDENTS
Hobgood et al. • EM RESIDENT ERRORS
T
ABLE 1. Reasons for Reporting Errors to Emergency
with 49% of programs formally following up ver-
bally communicated errors with written documen-
tation.
Morbidity and mortality conference was the
most used error-based teaching conference (94% of
programs). Morbidity and mortality conference
was performed monthly at 62% of the programs
and weekly at 20% of the programs.
Quality assurance programs varied widely. Al-
though 76% of the programs had a QA case review
conference, only 44% of the programs provided
written individual reports of QA deficits. Twenty-
five percent of the programs provided a written
group QA report and 39% of the programs provided
only a verbal report. The QA deficits were followed
up by re-auditing individuals at 39% of the pro-
grams and re-auditing group performance at 61%
of the programs. Seventeen percent of the pro-
grams had no mechanism in place for following up
errors detected by the QA process. The EMRDs
noted a number of different reasons why errors
were reported to residents (Table 1).
Medicine Residents
Percentage of
Reason for Reporting Errors
Residency Programs
Improve performance
Change behavior
Enhance responsibility
Improve compliance
Residency review committee
Joint Commission on Accreditation
of Healthcare Organizations
Other
66.75%
55.9%
31.2%
30.1%
24.7%
14.0%
2.2%
ipate in the study. Nonresponders were mailed a
second identical survey. The EMRDs were assured
that their responses to the questionnaire would
be held in strict confidence and the data would be
compiled anonymously. We surveyed EMRDs be-
cause of their unique educational role with the EM
residency program and departmental error man-
agement systems.
Resident participation in error management
systems varied. The involved resident presented
his or her case at morbidity and mortality confer-
ence at 39% of the programs; cases were solely pre-
sented by faculty at 48% of programs. When fac-
ulty were involved with morbidity and mortality
conference case presentations, the presenting fac-
ulty member was the EMRD at 20% of the pro-
grams. Morbidity and mortality conference case
presentations were performed anonymously at
58% of the programs. The three most common rea-
sons cited for this presentation style were to en-
hance teaching (39%), to avoid embarrassment
(28%), and to avoid individual blame (24%). When
the involved resident was identified, the two most
common reasons cited for this method were to en-
hance teaching (39%) and to enforce personal re-
sponsibility for committing the error (16%).
Survey Content. The survey instrument evalu-
ated five areas of EM resident clinical error man-
agement: 1) methods for tracking and reporting
resident errors; 2) resident participation in error
management; 3) resident remediation; 4) satisfac-
tion of EMRDs with the current error reporting
mechanisms, their educational value, and their
ability to identify and prevent errors; and 5)
EMRDs’ perceptions of faculty and resident satis-
faction with their current error management sys-
tems.
Data Analysis. Results were tabulated anony-
mously. Percentage of positive responses were tab-
ulated for each possible response and data were
reported as percentages.
RESULTS
Resident participation in QA tracking and re-
porting systems also varied. At 46% of the pro-
grams, residents developed and performed QA au-
dits, while 40% of the programs required residents
to perform predeveloped audits. Twenty-three per-
cent of the programs did not require residents to
participate in the QA process.
The response rate was 86% (96/112). Three pro-
grams responded but were unable to complete the
survey because their programs had not yet en-
rolled a class. These three respondents were ex-
cluded from further analysis.
All of the responding residency programs had
error management systems in place to track and
report clinical errors by residents. These consisted
of morbidity and mortality conference (94%), qual-
ity assurance (QA) audit review conference (76%),
and radiographic and electrocardiogram (ECG)
overread conferences (4%). Sixty-four percent of
the programs used QA audits and 60% of the pro-
grams performed continuous quality improvement
(CQI) on emergency department (ED) cases to
identify and track errors. Errors were verbally
For methods of resident remediation, 49% of the
EMRDs reported that no resident remediation was
required after committing a clinical error. For the
programs that required remediation, the various
methods used by EMRDs are listed in Table 2.
For the overall satisfaction of EMRDs with
their error management systems, 58% reported
their systems to be ‘‘good’’ and 13% reported their
systems to be ‘‘excellent’’ or ‘‘outstanding.’’ The
EMRDs rated the educational value of morbidity
and mortality conference to be ‘‘outstanding’’ (11%)
communicated to residents at 83% of programs, or ‘‘excellent’’ (53%). In rating their current error

ACADEMIC EMERGENCY MEDICINE • November 2000, Volume 7, Number 11
1319
T
ABLE 2. Methods of Remediation for Emergency Medicine
management systems to detect key errors or assist
in preventing future errors, none of the EMRDs
reported their systems to be ‘‘outstanding’’; 14% of
EMRDs believed their systems were ‘‘excellent’’
and 47% reported them to be ‘‘good.’’
More EMRDs perceived that other faculty (47%)
and residents (54%) shared their satisfaction with
the overall error management systems. The
EMRDs also believed faculty (44%) and residents
(51%) perceived morbidity and mortality confer-
ence to be a significant educational tool. Of the
EMRDs, 15% perceived that their fellow faculty be-
lieved their current error management systems
were ‘‘excellent’’ or ‘‘outstanding’’ for detecting key
errors.
(EM) Residents
Percentage of
Method of Remediation
Residency Programs
None
Lectures
Written reports
Extra clinical duties
Dependent on error
Conference with EM residency director
48.9%
24.7%
17.2%
8.6%
7.5%
7.5%
ingrained attitudes of physicians regarding ac-
countability and blame, which tends to suppress
open error reporting.8,9
The purpose of this study was to investigate the
systems EMRDs use to identify and report clinical
errors made by EM residents and their satisfaction
with error-based teaching as an educational tool.
Our data revealed that all EM residency programs
provided a format for discussion of errors, either
individually or in a conference format. Overall, the
EMRDs rated morbidity and mortality conference
to be an excellent educational tool and perceived
that other faculty and residents also valued its ed-
ucational benefits.
In 1991, Wu et al. demonstrated that a house-
officer who accepted responsibility for an error was
more likely to undergo a beneficial change in prac-
tice. This acceptance of responsibility for error was
strongly associated with emotional stress, with
houseofficers reporting remorse, anger, guilt, and
feelings of inadequacy. Despite these feelings,
houseofficers were uniformly reluctant to inform or
discuss mistakes with supervising physicians.10
The results of this study demonstrated that mor-
bidity and mortality conference cases are pre-
sented anonymously in almost 60% of programs,
with the remaining programs identifying the resi-
dent involved in the case. The fact that many EM
residency programs incorporate open discussion of
errors may serve to educate residents that evalu-
ating errors can be performed in an open manner.
While our results demonstrated that most
EMRDs are pleased with the educational value of
their error-based teaching conferences, very few
believed that their error management systems
were outstanding or excellent in assisting to iden-
tify key clinical errors or preventing future errors.
This perceived weakness may serve as a marker
for ED clinical operations directors to address with
novel error management systems and studies in
the future.
D
ISCUSSION
‘‘Above all do no harm.’’ This principle from the
Hippocratic oath defines the cultural standard for
physicians in the delivery of health care.4 This ad-
monition, often interpreted to mean error-free per-
formance, is socialized early in medical school and
residency training. The general expectation is
clear: physicians should never make errors while
providing patient care.4,5,8 Any error is perceived as
a failure on the part of the involved physician.4,8,11
A direct outgrowth of this cultural standard is
the reluctance among physicians to acknowledge
their mistakes. Numerous studies have demon-
strated that physicians are uniformly reluctant to
discuss their errors, even though physicians ac-
knowledge that they do occur.4,10,12 These studies
suggest that fear of criticism and personal embar-
rassment are the primary reasons for this behav-
ior. Many physicians seem to fear that if they ac-
knowledge an error, peers will regard them as
incompetent or inadequate.4,5,11 In addition, the
overall public perception mandates that health
care delivery be free of error.4,8,10 When errors do
occur, physicians often fear retribution through the
legal system. This further enhances the fear of
open reporting of errors.8,9
The industrial quality management community
views errors as inevitable.4,9 While individuals are
not absolved of responsibility for error, systems
have been developed to identify errors, and all er-
rors are tracked.13 Using this technique, many in-
dustries have developed and incorporated sophis-
ticated error detection systems that allow for early
error correction or prevention. All of these systems
have been predicated upon the principle that hu-
man error will occur and systems must be designed
to incorporate methods to detect and track their
occurrence. Each of these events, when identified,
provides an opportunity for improvement.4,9,13 Im-
plementation of these systems in medicine has
The Joint Commission on Accreditation of
Healthcare Organizations has initiated a broad-
based process to improve the health care system’s
ability to detect and prevent error.9,13 This change,
proven difficult because of the lack of open report- however, may take time to develop. A 1990 study
ing. This has been postulated to be a result of the reported that only 28% of U.S. medical schools of-

1320
RESIDENTS
Hobgood et al. • EM RESIDENT ERRORS
fered medical students or physician residents di- tect baseline error occurrence, to the best of our
dactic education on QA.13 Thus, future physicians knowledge this has never been documented. These
may be inadequately trained to approach organi- methods could have error detection capacities that
zational problems in error management, further vary widely both within and between institutions.
perpetuating the culture of not openly discussing
Future studies should be directed toward ex-
amining the impact of behavior modification on
errors.9,13,14
In 1998, the President’s Advisory Commission EM residents who have undergone a training pro-
on Consumer Protection and Quality in the Health gram in QI and open acknowledgment of clinical
Care Industry ranked error prevention as a top errors. In addition, future research should assess
priority for the industry.9 Increasingly, regulatory the effect of teamwork training on EM residents.
agencies and credentialing committees are requir-
ing physician participation in medical systems
C
ONCLUSIONS
revision.13 Because of these requirements, the
Accreditation Council for Graduate Medical Edu-
cation has recommended that training programs
ensure graduates understand the principles of
quality improvement (QI).14 This has been rein-
forced by the Pew Health Professions Commission,
who recommended that all medical trainees par-
ticipate in QI projects at some point during their
medical training.15 These mandates will require
broader resident education in the principles of QI
and the development of more effective error man-
agement systems.
All EM residency programs have systems to track
and report resident errors. Resident participation
varies widely between systems, as does resident
remediation processes. Most EMRDs are satisfied
with their systems but few EMRDs rate them as
excellent in the detection or prevention of error.
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LIMITATIONS AND
F
UTURE
Q
UESTIONS
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