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Learning to Prevent Medical Mistakes in Caring for Stroke Patients

Medical errors and adverse events can happen in patients with stroke, and hospital procedures need to be modified to reduce the likelihood// of error and patients getting hurt, according to a study.

For the study, researchers analyzed provider-reported adverse events and errors within a voluntary and mandatory event reporting system in stroke patients admitted to Strong Memorial Hospital at the University of Rochester Medical Center in Rochester. Adverse events are defined as an injury to a patient occurring during medical management, not necessarily because of an error. Medical errors are defined as incorrect actions or plans that may or may not cause harm to a patient.

Of the 1,440 stroke patients studied, 12 percent, or 173 patients, experienced an adverse event. A total of 201 events were reported for the 173 patients. “Learning about what caused these events is the only way to keep them from happening again,” said study author Robert G. Holloway, MD, MPH, with the University of Rochester Medical Center, and Fellow of the American Academy of Neurology.

Of the total 201 events reported during the study, 18 were near misses, which are defined as an error that does not reach the patient, and 183 were adverse events.

Of the 183 adverse events, 86 were preventable, 37 were not preventable, and 60 were indeterminate. Of the preventable adverse events, 37 percent were transcription/documentation errors, 23 percent were failure to perform a clinical task, 10 percent were communication/handoff errors between providers, and 10 percent were failed independent checks/wrong calculations.

“Although most patients who experienced a preventable adverse event were not seriously harmed, adverse events do lead to temporary discomfort, longer hospital stays, and in some cases, serious injury, or the potential for legal action,” said Holloway. “If these figures were applied to the nearly one million patients admitted to U.
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