Beyond the Medical Record

Medical record reports are not always sufficient for quantifying and understanding medical errors. Qualitative inquiries can be used to supplement and confirm large-scale quantitative data analyses. In this study 26 semi-structured interviews were conducted with randomly selected residents from a teaching hospital. Interviews collected information about recent medical errors and how those errors were acknowledged. Data was analyzed using Ethnograph (a computerized qualitative coding program) and traditional content analysis methods. Medical errors were coded as either “Documented,” “Discussed” or “Uncertain.”

Key Findings:

  • There were 73 cases identified as medical errors.
  • Forty-one percent of identified medical errors were formally acknowledged and “Documented” in the medical record, 33 percent were “Discussed” but not documented and 26 percent were classified as “Uncertain.”
  • Medication errors accounted for 12 of the 73 identified cases.