Annals of family medicine
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Annals of family medicine · Jul 2004
Multicenter StudyA string of mistakes: the importance of cascade analysis in describing, counting, and preventing medical errors.
Notions about the most common errors in medicine currently rest on conjecture and weak epidemiologic evidence. 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. ⋯ Cascade analysis of physicians' error reports is helpful in understanding the precipitant chain of events, but physicians provide incomplete information about how patients are affected. Miscommunication appears to play an important role in propagating diagnostic and treatment mistakes.