CLINICAL OBSTETRICS AND GYNECOLOGY
Volume 51, Number 4, 656–665
Errors and Analysis
of Errors
MAUREEN A. MULLIGAN, RN, JD, BSN*
and PAT NECHODOM, MPHw
*School of Pharmacy, Utah Poison Control Center; and
w Epidemiology Department, School of Medicine, University
of Utah, Salt Lake City, Utah
Abstract: Methods of analyzing errors and proactively
preventing errors are discussed. A framework for
using these concepts is presented.
Key words: patient safety, quality improvement tools
Introduction
Every hospital and physician’s group
needs a quality program that incorporates
all the methods of improving patient
safety, analyzing errors, and improving
quality together in 1 program rather than
isolated programs. The goal of the pro-
gram should be to improve the outcome
of quality and the safety of the healthcare
the patient receives. Quality of care and
patient safety is for outpatient programs
and inpatient care. Most patients receive
the majority of their healthcare as an
outpatient not an inpatient.
The traditional approach to healthcare
errors has been an error occurred when a
patient was harmed. The harm may be
death or a lesser injury. The recognition of
harm initiated a process of reviewing the
Correspondence: Maureen A. Mulligan, RN, JD, BSN,
School of Pharmacy, Utah Poison Control Center,
University of Utah, Salt Lake City, UT. E-mail:
mo.mulligan@gmail.com
CLINICAL OBSTETRICS AND GYNECOLOGY / VOLUME 51
656
r 2008, Lippincott Williams & Wilkins
patient’s care to determine if the standard
of care had been met. Mortality and mor-
bidity (M and M) committees would dis-
cuss what individual would be blamed for
performing a task wrong or omitting a
task or decision of care. The M and M
committee usually consists of physicians
only and the reviews resulted in decisions
by this group. The traditional decisions of
these reviews included humiliation of the
involved healthcare professional, requir-
ing the health professional to become
more educated on a topic (at times when
this was not needed), encourage them to
become more careful, pay closer attention
to detail, or as a final resort, terminate
their position on the medical staff. This
process has resulted in minimal change to
the frequency of healthcare errors. Most
errors occur as a result of failure of the
system of healthcare and not just one
individual’s failure. A change is required
to restructure the process of how errors
are reviewed and analyzed within the
practice of healthcare if improvement in
the whole system is the goal.
Quality was historically driven by the
Joint Commission or for physician offices
requirements by the state or insurance
company that paid for the services. Many
/ NUMBER 4 / DECEMBER 2008

organizations are only practicing compli-
ance of these standards when it comes to
decreasing errors and improving quality.
Today, if an organization’s goal is to meet
quality standards, their quality practice
is in the early 1990s. Improving quality
and decreasing errors for the patients
requires more than meeting regulatory
requirements. A quality program that
proactively analyzes possible errors incor-
porating multiple methods is the ap-
proach that will be discussed in this
chapter.
Quality Program
The quality program needs to define what
it includes and the goals it wants to reach.
This can be reviewed yearly or more
often as needed. The frequent changes in
quality requirements by the federal gov-
ernment, state governments, and other
entities require a frequent review. The
overall structure of the program should
be the integration of quality and patient
safety. These should not be completed as
separate programs, as this leads to dupli-
cation of effort, time, and money.
The overall monitoring of the outcome
of care should be the cornerstone for the
program. The key determinant is out-
comes of care and not outcomes of health-
care processes. The final determination of
how well care is provided for quality and
safety is the final outcome to the patient.
Examples of outcomes that should be
routinely monitored are mortality of the
mother, infection rates for mothers post-
delivery, infection rates for low-risk sur-
gical patients, and an outcome for babies
would be the incidence of group B strep.
The Joint Commmission’s monitoring of
third and fourth degree laceration rates
trends process measurements, not out-
come measurements. Outcome measure-
ments need to be reviewed as rates. When
comparing data from one point in time to
another point in time, a rate allows for an
increase or decrease of the denominator
Errors and Analysis of Errors 657
and gives a good comparison between
different points in time. An example of
this is when there is a decrease in the
number of deaths that may be owing to
a decrease in the number of patients being
treated. This is frequently seen when
comparing the number of errors being
reported for specific areas and concern
grows owing to an increase in errors
occurring, but there is an increase in
patients. If a rate is used, this increase or
decrease in the denominator is taken
into consideration and allows for an actual
comparison between time periods.
Quality Indicators
Quality is the actual healthcare a patient
receives, not the methods used to improve
the care. Quality indicators when routi-
nely trended and monitored allow for
reviewing if patient care is improving.
Quality indicators need to trend patient
errors. The traditional method of report-
ing when an error occurs is for the physi-
cian to inform the M and M committee or
in an organization through an error re-
porting system. An error reporting system
is an important part of the overall pro-
gram. Once errors are reported, they
should be grouped and trended together.
If the program only performs individua-
lized reviews of errors and then chastises
the professional, hiding errors will be-
come the goal. If the physician is encour-
aged to only report when harm occurs,
limited improvement in the quality of
patient care occurs. It has become appar-
ent that a different way of measuring
errors is required to turn the focus to the
quality of care being delivered to the
patient and improving the safety. Error
reporting needs to become data that are
used to improve a flawed system. When the
focus is turned to the failings of the system
and the solutions target system improve-
ment, professionals are more willing to
report what has happened.
658 Mulligan and Nechodom
At a minimum, each physician group
should be aware if a ‘‘never event’’ occurs
to any of their patients while they are
providing healthcare. The National Qual-
ity Forum (NQF) has created standards
that are called never events. These never
events are defined as errors in medical
care that are serious, largely preventable,
and of concern to the public. These
started as voluntary consensus stan-
dards.1 Currently, there are states that
require reporting if these events occur,
with Utah being among the reporting
states.2 Other states will not pay for the
care these patients received if a never
event occurred, as in the case of New
York.3 The never events that may possi-
bly occur to an Obstetrics and Gynecol-
ogy (OB GYN) physician or group are as
follows:
 Artificial insemination with the wrong
donor specimen or egg.
 Unintended retention of a foreign object.
 Intraoperative or immediately postopera-
tive death in an ASA class 1 patient.
 Infant discharged to wrong person.
 Maternal death or serious disability asso-
ciated with labor or delivery in a low-risk
pregnancy while the patient is being cared
for in a healthcare facility.
 Death or serious disability (Kericterus) as-
sociated with failure to identify and treat
hyperbilirubinemia in neonates.
If any of these events occur, the physi-
cian must review each case to determine
what steps need to be taken to improve the
patient’s care, what processes may have
caused the event, and what solutions may
be implemented to avoid recurrence of
this error. How to perform this review is
discussed later in this chapter.
The NQF is also working on consensus
standards for perinatal care. These are
measures of care received during the last
trimester of pregnancy through hospital
discharge of mother and child.4 When
these measures are finally determined,
it is important for physicians to review
whether or not they are meeting these
standards.
On May 15, 2008, the NQF endorsed
48 consensus standards including mea-
sures addressing hospital readmission,
prevention, and care of venous throm-
boembolism. Some specific OB GYN
measures in this group are average LOS
for deliveries and death in low mortality
Diagnostic Related Groups (DRGs)
(pregnancy and delivery is considered a
low mortality DRG).5 The NQF stan-
dards are voluntary standards but as more
organizations benchmark and improve
care in these areas, they become the norm.
These are measures that all OB GYN
physician groups should include in their
quality program for analysis and bench-
marking to determine variances in care.
Every physician should know how his
practice is impacting these measures.
A death in a low mortality DRG is one
of the standards that need to be reviewed
first for the appropriateness of this deter-
mination. Labor and delivery is unique as
even if a patient is transferred to another
hospital because of a cardiac arrest, the
principal diagnosis remains delivery. This
results in patients ending up as a death in a
low mortality DRG when they had a
catastrophic event at another hospital.
So you may have patients in this group
that are not reflective of the care pro-
vided. It is important for physicians to
understand what is included in these
groupings of administrative date.
The Agency for Healthcare Research
and Quality (AHRQ) has created a series
of reports derived from administrative
(financial) data that are used by many
organizations, including states, to deter-
mine which healthcare institutions pro-
vide safe care.6 Many hospitals are
required to report their financial data
with DRGs that are based on a collection
of International Classification of Diseases
and related health problems Ninth Revi-
sion (ICD-9) to the individual state health
departments. Many of the state health

departments then sell this data to Centers
for Medicare Services (CMS) and other
companies. Administrative or financial
data are compiled by coders who review
patients’ medical records and enter speci-
fic codes depending on what has been
documented by the physician in the med-
ical record. By law, coders may only
document codes on the basis of the phy-
sicians’ documentation. Physicians can-
not depend on coders noting nursing or
pharmacy documentation; the coders are
not allowed to use this information in
their coding determinations. These ad-
ministrative data or claims data are used
to rank institutions by calculating error
rates and creating risk adjustments. These
risk adjustments use algorithms devised
by the organization creating the report.6
Some states put these data on internet web
sites, others retain privacy, sending the
information to the physicians and orga-
nizations involved in their patient’s care.7
Some insurance companies, such as Blue
Cross and Blue Shield, post these data on
an intranet restricted to members.
The AHRQ patient safety indicators
include the following obstetric indicators:
 Birth Trauma OB trauma—vaginal with
instrument,
 OB trauma—vaginal without instrument,
and
 OB trauma—cesarean section.
The AHRQ indicators definitions can
be found on CMS’s website with the list of
the specific ICD-9 codes that are used for
each indicator. These indicators were cre-
ated by a panel of physicians and nurses
after a review of patient ICD-9 codes. A
review of the literature reveals that evi-
dence discussing these complications as
measures of quality care are very scant.4
These measures are currently being used
by several states to assess minimum levels
of quality care and whether a hospital and
its physicians are meeting the expected
rates for quality.5 Some groups are using
Errors and Analysis of Errors 659
this information to make comparisons
between physician groups and not just
hospitals. Other organizations are using
these data to determine what the appro-
priateness of care is. These data need to be
routinely reviewed by physicians and
other team members so that improve-
ments may be made to the healthcare
systems.
Quality Improvement Tools
HUMAN FACTORS
Rather than just measuring the data for
the care a patient received, a patient’s care
needs to be reviewed and analyzed against
the scientific-based evidence to determine
if appropriate care was delivered. If it is
determined that the care was not appro-
priate, then a review using human factors
and cognitive psychology should be per-
formed. This will determine what changes
need to be made to the system to provide
for sustained change so that the errors do
not occur again and the system is made
safer for all patients.
Errors are the inevitable by-product of
staff performing the best they can in a
system structure that allows error occur-
rence.8 In the year 1999, the IOM recom-
mended that healthcare use the same
theory and approach as other industries.
These industries have applied human fac-
tors analysis to reduce errors.9 Human
factors is an applied science that uses
knowledge of human abilities and limita-
tions to design systems, organizations,
jobs, machine tools, and products for
safe, efficient, and comfortable human
use.10 This interaction between healthcare
staff and healthcare systems creates or
prevents errors in healthcare. The study
of this interaction requires knowledge of
human limitations and abilities.
Patient care providers in healthcare are
highly educated and trained in patient
treatments. Analyzing decision making
errors requires knowledge of how the
660 Mulligan and Nechodom
human brain works. There are limits to
our brain functions and how it uses
healthcare knowledge. This knowledge is
retained in the working memory and the
knowledge base (long-term memory) of
the brain.11 Working memory is the part
of memory that an individual uses when-
ever routine tasks are performed. A lim-
ited number of ideas, sounds, or images
can be mentally maintained at one time in
the working memory. Items in working
memory are rapidly lost if no effort is
made to maintain them.11 If an individual
works to maintain these items, the infor-
mation goes to knowledge base or long-
term memory. The capacity of working
memory is limited to 5 to 9 independent
items. If there are delays longer than a few
seconds between receiving information
and then using it, the information may
be lost. If new information is received too
rapidly, the new information may inter-
fere with ‘‘old’’ information. If the infor-
mation is similar in meaning or sound,
confusion may be created between the
different types of information. There
may be confusion when there is similarity
in the material to be remembered and
competing tasks that are being carried
out at the same time.11
Working memory receives continuous
input from our senses and also from the
knowledge base. Information is trans-
mitted to the brain through input from
the senses. There are limitations within
our senses. What and how we see things
impact how this information is trans-
mitted. Vision is the dominant sense in
terms of input. A procedure performed
when vision is partially impaired as with
low lighting may lead to errors occurring.
What and how we see things impact how
information is transmitted within the hu-
man brain. The amount of illumination
can distort our visual perception. These
visual misperceptions may result in pa-
tient errors.12 As healthcare workers age,
increased lighting is needed owing to
myopia. Computer displays are more
easily visualized when they are at eye level.
Monitors should have the capability of
being raised and lowered so that they are
at eye level. Color blindness needs to be
taken into consideration when planning
work places that will provide safer patient
care.12
Working memory is susceptible to loss
of items by interruptions from coworker.
All physicians are frequently interrupted.
This part of a process is never documen-
ted and is very difficult to determine if it is
the cause of an error unless someone is
watching. Working memory is also sus-
ceptible to loss of items owing to noisy
environments. Writing orders for a pa-
tient in the middle of a care unit is one of
the noisiest areas in the healthcare setting,
yet it is our expectation that no errors will
be made during this activity.
While using working memory, humans
are aware of the product and not necessa-
rily the process required to complete the
product. Healthcare professionals use
working memory during the routine pro-
cess and procedures of providing patient
care. These are the basic skills and tasks
performed by healthcare professionals on
a daily basis. The limitations of working
memory need to be taken into consi-
deration when planning new processes,
improving current processes, and improv-
ing current procedures that are part of
these basic skills and tasks performed.
Knowledge base memory (long-term
memory) has an unlimited storage capa-
city and an unlimited length of time
information is stored. Information in
the knowledge base is processed slowly.
Everyone has areas where their knowl-
edge is more complete. One aspect that
can lead to error is if the healthcare in-
dividual does not recognize that their
knowledge base is not complete. Another
issue is that the individual may have the
knowledge; however, it is not activated
at the time it is needed as the situation
does not match a previous encounter or
practiced experience.13 It is very difficult

to learn and apply the large amount of
new information that is available in
healthcare each year. When determining
how to prevent errors, we need to remem-
ber that information may be processed
simultaneously by working memory and
knowledge base.14
Jens Rasmussen developed 3 levels of
performance for decision making. This
is also called levels of problem solving.
These levels are used by physicians as they
are making decisions regarding patient
care.
Skill-based level: Routine, highly practical
tasks in a largely automatic fashion with
occasional conscious checks on progress.
Rule-based: Apply memorized or written
rules. It is likely to be a situation one is
educated or trained to deal with, or there is
a procedure to follow. Automatically
match the signs and symptoms of the pro-
blem to some stored knowledge structure.
Knowledge-based level: It is usually a
novel situation where actions must be
planned on-line using a conscious analytic
process and stored knowledge. This is a
slow process and used only when rule-
based fails.14
The skill-based level and the rule-based
level are most often used during routine
situations that are encountered frequently
during a physician’s daily practice. All 3
performance levels may be used during an
activity. The more experience a healthcare
worker has in a specific area influences
what level of performance is used in mak-
ing a decision. If a resident physician is
relatively new at performing a procedure,
the resident will use rule-based or even
knowledge-based information for pro-
blem solving. An OB GYN physician
who has performed the procedure hun-
dreds of times will use skill-based infor-
mation. The level of performance of
decision making is important in determin-
ing how to prevent the error.
Reason14 defines an error as the failure
of a planned action to achieve the desired
Errors and Analysis of Errors 661
ends. Reason summarizes the following
errors types:
 Violations: This is a deliberate decision to
act in a nonstandard way. The violation is
intended but the results are not intended. A
violation may be an appropriate action
when policies and procedures are not cur-
rent. Noncompliance of a standard may be
seen as essential to accomplishing the re-
quired work. A violation does not assume
patient harm has occurred.
 Slips and lapses: The person correctly as-
sesses what needs to be carried out and acts
accordingly, but there is an unintended
failure of execution. An omission of a step
in carrying out a planned action is the most
common slip or lapse. This is the most
common error when a step is missed during
a procedure or task. Individuals frequently
do not even realize that a step was omitted.
 Mistake: An error in which the person fails
to form the correct intention as to what act
to perform. This is a decision-making error.
There are several types of mistakes.
 Rule-based mistake: There is a misapplica-
tion of a good rule. This may be owing to
rule rigidity. At the time the decision was
made to apply the rule, there may not have
been sufficient data or information about
the given situation. There is an application
of a bad rule or failure to apply a good rule.
 Knowledge-based mistakes: These occur
when individuals have run out of prepack-
aged solutions and have to respond by trial
and error. This may be the result of insuffi-
cient knowledge of the healthcare worker.
The only time that additional educa-
tion is needed by an individual making an
error is when a knowledge-based mistake
was made and maybe when a rule-based
mistake is made. Traditionally this is the
most common improvement suggested
for preventing future errors when in fact
it is rarely one of the causes of an error.
The science of human factors and cog-
nitive psychology needs to be used by
healthcare professionals when they are
determining how an error was made dur-
ing the care of a patient. This is a signifi-
cant change in reviewing these errors and
662 Mulligan and Nechodom
if followed as part of an improvement of a
process, sustained improvements may be
made to the system.
ROOT CAUSE ANALYSIS
A root cause is a problem solving techni-
que to determine why an error occurred.
The purpose of a root cause analysis is to
identify the single cause of an error; then
you determine an action plan for fixing
this error. There are multiple steps for
determining the root cause of an error.
These steps involve collecting and analyz-
ing data as to why the error occurred,
hypothesizing the cause, and verifying
the root cause. The reason for performing
a root cause is the belief that if the cause is
corrected then reoccurrence of the pro-
blem will be prevented.15 However, from
a system prospective there is seldom one
cause of an error. An awareness of how
limiting this approach can be is being
recognized.16 One of the problems with a
root cause analysis is that a process or
procedure will probably fail differently
for each patient and a method is needed
to look at multiple ways that a system
can fail.
FAILURE MODE EFFECTS ANALYSIS
Failure mode effects analysis (FMEA) is a
process of proactively determining what
errors may result from the system of care
provided. FMEAs were first used in the
engineering industry during the design of
a new product. An FMEA requires staff
and significant time for performing the
FMEA. This is a process that must be
used as it will result in multiple changes to
a system if fully completed resulting in
error prevention and decrease the harm to
patients. An FMEA requires the inclusion
of human factors and cognitive psychol-
ogy when determining where a process
can fail. It is frequently the interaction
between healthcare professionals and the
organization that results in the failure
of the process or provision of care to the
patient. An FMEA needs to include all
members of the team to adequately deter-
mine where a process might fail and how
to prevent this failure. An FMEA requires
the team to identify each step in a process
of care. Then it determines all the different
ways this process may fail and the cause of
the failure. What is unique with an FMEA
is the next step where you determine a
numerical score for the likelihood of the
potential failure, the detectability of the
failure, and third the severity of the fail-
ure. Each of these numerical scores is
based on 1 to 10. Example for severity: 1
is no harm to the patient and 10 is death;
detectability: 1 easy to detect and 10 is
difficult to detect; and likelihood: 1 is very
unlikely to occur and 10 is frequently will
occur. These 3 numbers are then multi-
plied and it gives you a risk priority
number (RPN). The RPN score can help
you determine which cause of the failure
you want to prevent first. The highest
RPN number should be the failures that
are improved first before the lower RPN
failures. This is because it is difficult to
improve all of the failures and the im-
provements need to be prioritized. Next,
you add all the RPN numbers together to
determine the total RPN. The actions
taken to prevent the failures are the im-
provements to the system. Then deter-
mine the improvement, you need to
reanalyze the failure and RPN to deter-
mine if you are actually decreasing the
RPN for the failure. Then determine the
action plan and recalculated the RPN, on
the basis of these actions, subtract the new
total RPN number from the original total
RPN number.17 This helps determine the
impact of the improvements on the system
of care provided to the patient.
The primary purpose of an FMEA is to
improve the quality of care for multiple
patients. The key to an FMEA is that you
are proactively preventing harm from oc-
curring. Two examples of FMEAs that
were performed proactively at the Uni-
versity of Utah Hospitals and Clinics are
as follows. One FMEA performed an

analysis of errors owing to infusion
pumps and medications and then also
reviewed potential failures and preven-
tion of the failures by all the different
types of infusion pumps. The next step
was to perform an FMEA on the different
infusion pumps, that is, smart pumps and
determine which one prevented most of
the errors from occurring. This informa-
tion was used by the technology commit-
tee to decide which infusion pumps to
buy. Then, ongoing monitoring of infu-
sion pump errors allowed for analysis of
this decision and prevention of errors.
The second example was an FMEA de-
termining all the failures of improper
items being brought into a magnetic
resonance imaging (MRI) room. This
FMEA started off as a root cause analysis
from 1 patient error and was changed to
an FMEA after determining the 1 failure,
but realizing that there was significant
opportunity for failures with other pa-
tients and staff. An FMEA may be used
in conjunction with a root cause analysis.
Harm happens to a patient and the occur-
rence is analyzed for the root cause of the
failure with this patient, the team may
determine that there are other ways this
process could fail in the future. Then, the
team switches from performing a root
cause analysis to an FMEA, which will
decrease the possibility of future harm to
multiple patients.
One of the problems with an FMEA or
a root cause analysis is that after a patient
error occurs that results in harm, an orga-
nization may revise its policies and pro-
cedures. The policies and procedures
become more detailed and cumbersome.
This revision in itself cannot prevent
errors. The number of possible events
far exceeds the number of rules that can
be set up.18 Over time, many of these rules
that make up policies and procedures
become more and more restrictive, some-
times restricting procedures sufficiently so
that it is actually difficult to get the job
performed.18 Adding to or enforcing pro-
Errors and Analysis of Errors 663
cedures does not guarantee compliance
with the procedure. The more steps in-
volved in a procedure, the more chances
there are that a step may be omitted and
result in an error. The stricter a procedure
is written, the less likely it has a broad
application. Also, changing a procedure
may increase the likelihood that a differ-
ent type of error may result from the
change. The more detailed and strict a
procedure is written, the more likely a
violation of the rule will be the only choice
for the staff. Simplification of procedures,
not increasing the details in a procedure,
should be the goal. The purpose of an
FMEA or root cause analysis is not to
increase the number of rules or proce-
dures in an organization. The goal is to
improve the process of performing the
procedure.
In addition to looking at the failures
that are the result of the organization’s
processes, the failure mode needs to look
at whether or not any of the failures are
the result of the community. These may
examine the health literacy of the patients,
the multiple organizations that a physi-
cian may be dealing with, the different
type of education all the healthcare work-
ers have that may result in error, and
harm to the patient because the system
failed. An example of this is in the MRI
FMEA that was performed at the Uni-
versity of Utah Hospitals and Clinics, 1
type of failure was the equipment that
firefighters or police officers may try to
bring into an MRI and how the MRI staff
would prevent that failure.
HUMAN ERROR INVESTIGATION
Rather than a root cause analysis being
performed any time a patient is harmed, a
human factor investigation should be per-
formed. A systems approach for analyz-
ing errors is to use a human error
investigation. In his book, The Field Guide
to Human Error Investigation, Dekker8
sets out valuable information on how to
perform a human error investigation. The
664 Mulligan and Nechodom
basis of this investigation is a series of
questions for analyzing actions by indivi-
duals who are involved with the error.
Gary Klein developed these questions to
be asked at the review of the event:
 What were you seeing?
 What were you focusing on?
 What were you expecting to happen?
 Were you reminded of any previous experi-
ence?
 part of a human factors investigation.
Did this situation fit a standard scenario?
 Were you trained to deal with this situa-
tion?
 Were there any rules that applied clearly
here?
 What goals governed your actions at the
time?
 Were there conflicts or trade-offs to make
between goals?
 Was there time pressure?
 Did you discuss or mentally imagine a
number of options or did you know straight
away what to do?
 Did the outcome fit your expectation?
Dekker, Sydney. The Field Guide to
Human Error Investigations
These questions provide the informa-
tion needed to determine how the error
occurred from a systems perspective
rather than a blame perspective. When
you are performing an investigation after
an error has occurred, remember that
hindsight is 20/20. To obtain an under-
standing of other people’s assessments
and action, it is necessary to understand
the perspective of the individuals involved
before, during, and at the time the error
occurred to obtain an understanding
of the assessments and actions that take
place.8 If the science of human factors is
not used when analyzing deficiencies in
patient care, then we are continuing to use
the same approach of problem solving
and just calling it a new name.
Human factor analysis should be per-
formed as a proactive approach to create
a safer environment for the patient and
staff as part of an improvement project.
Human factor analysis will provide infor-
mation on current system weaknesses and
aid in the development of an improve-
ment plan designed to prevent identified
failures. If using FOCUS PDCA, a
human factor analysis is performed as
part of the FOCUS. A human factor
analysis can also be used as part of a
FMEA. It identifies the areas that may
fail. A human factor analysis is always
Quality Committee
Rather than M and M committees, phy-
sicians should develop a quality commit-
tee that includes learning about what
caused errors and complications. In 1
survey, less then half of the physicians
received any data regarding process, out-
comes, or patient satisfaction. The vari-
ables for the results included practice size
and were they salaried physicians or
independent of the organization.19 Less
than 10% of the physicians stated that
clinical quality was a factor in determin-
ing compensation.19 If physicians are not
receiving these data and information, how
can they improve their own practice?
The quality committee needs to im-
prove the data that are being used for
benchmarking. This may need to include
a team of physicians and coders working
together to understand the pitfalls in
using administrative data for clinical
quality determinations. Even with these
pitfalls, the administrative data need to be
reviewed as it is becoming a national
standard.
This committee needs to use national
standards for setting priorities of what
needs to be improved, what should be
analyzed, and become proactive for the
future of healthcare. One reference is
Priority Areas for National Action Trans-
forming Health Care Quality that lists 20
areas of priorities for healthcare quality
and 1 is pregnancy and childbirth.20
The aim for pregnancy and childbirth is

‘‘to improve the quality of care provided
during pregnancy and childbirth by ap-
propriately using proven healthcare inter-
ventions at key time during pregnancy
and delivery, and successfully applying
these interventions to populations known
to be at risk.’’19 The committee needs to
actually improve the outcomes that the
patients achieve by setting priorities for
accomplishing improvements, determin-
ing what data will be routinely reviewed,
reviewing the data and determining what
needs to be improved on, perform human
factor analysis for never events, and
FMEAs for analyzing whole system pro-
cesses. Then, sustaining and measuring
the improvements is the next responsibil-
ity of the committee. When these methods
are routinely performed, the committee
will reach the goal of improving patient
care and making it safer.
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