Fully 80% of the errors that initiated cascades involved informational or personal miscommunication. Although 83% of the errors that ultimately occurred were mistakes in treatment or diagnosis, 2 of 3 were set in motion by errors in communication. RESULTS A chain of errors was documented in 77% of incidents. We tabulated the consequences to patients, both reported by physicians and inferred by investigators. The narratives were examined to identify the chain of events and the predominant proximal errors. METHODS Eighteen US family physicians participating in a 6-country international study filed 75 anonymous error reports.
We sought to determine whether cascade analysis is of value in clarifying the epidemiology and causes of errors and whether physician reports are sensitive to the impact of errors on patients. BACKGROUND Notions about the most common errors in medicine currently rest on conjecture and weak epidemiologic evidence.
