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Reporting of medical errors: An intensive care unit experience

2004· article· en· W2033999679 on OpenAlex
Stephen Osmon, Carolyn B. Harris, W. Claiborne Dunagan, Donna Prentice, Victoria J. Fraser, Marin H. Kollef

Why this work is in the frame

A frame that forgets how it found something cannot be audited. These are the routes that admitted this work.

affAt least one author lists a Canadian institution in the pinned OpenAlex snapshot.

Bibliographic record

VenueCritical Care Medicine · 2004
Typearticle
Languageen
FieldHealth Professions
TopicPatient Safety and Medication Errors
Canadian institutionsCARE Canada
FundersAgency for Healthcare Research and Quality
KeywordsMedicineIntensive care unitIntensive careObservational studyEmergency medicinePsychological interventionCritical care nursingMedical emergencyEmergency departmentProspective cohort studyHealth careIntensive care medicineNursingSurgeryInternal medicine

Abstract

fetched live from OpenAlex

OBJECTIVE: To determine the occurrence and type of medical errors in an intensive care setting using a voluntary reporting method. DESIGN: Prospective, single-center, observational study. SETTING: The medical intensive care unit (19 beds) at an urban teaching hospital. PATIENTS: Adult patients requiring at least 48 hrs of intensive care. INTERVENTIONS: Prospective reporting of medical errors. MEASUREMENTS AND MAIN RESULTS: During a 6-month period, 232 medical events were reported involving 147 patients. A total of 2598 patient days were surveyed yielding 89.3 medical events reported per 1000 intensive care unit days. The source of the reports included nurses, who reported most of the medical events (59.1%), followed by physicians-in-training (27.2%) and intensive care unit attending physicians (2.6%). One hundred thirty (56.2%) medical events occurred within the intensive care unit and were judged to involve patient careproviders who were working directly in the intensive care unit area. One hundred and two (43.8%) medical events were commissions or omissions that occurred outside of the intensive care unit during patient transports or in the emergency department and hospital floors. Twenty-three (9.9%) medical events leading to a medical error resulted in the need for additional life-sustaining treatment, and seven (3.0%) medical errors may have contributed to patient deaths. CONCLUSION: Medical errors appear to be common among patients requiring intensive care. Medical events resulting in an error can result in the need for additional life-sustaining treatments and, in some circumstances, can contribute to patient death. Patient healthcare providers appear to be in a unique position to identify medical errors. Institutions should develop formalized methods for the reporting and analysis of medical errors to improve patient care.

Fetched live from OpenAlex and de-inverted. Abstracts are not stored in this database: the inverted indexes are 8.6 GB of the frame’s 9.3 GB of text, and the host has 13 GB free.

Full frame distilled prediction

Teacher imitation

Not calibrated prevalence, not ground truth. Human validation pending. Learned from the 10,348 direct Codex labels and 10,348 direct Gemma labels. Candidate is the union of thresholded teacher heads; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels or direct frontier model labels.

metaresearch head score (Codex)0.001
metaresearch head score (Gemma)0.079
Version: codex-gemma-dda1882f352aValidation status: machine_predicted_unvalidated
Candidate categoriesMetaresearch, Insufficient payload (model declined to judge)
Consensus categoriesnone
DomainCandidate signal: none · Consensus signal: none
Study designCandidate signal: Qualitative · Consensus signal: Qualitative
GenreCandidate signal: Empirical · Consensus signal: Empirical
Teacher disagreement score0.134
Threshold uncertainty score0.999

Codex and Gemma teacher scores by category

CategoryCodexGemma
Metaresearch0.0010.079
Meta-epidemiology (narrow)0.0000.000
Meta-epidemiology (broad)0.0010.000
Bibliometrics0.0000.000
Science and technology studies0.0000.001
Scholarly communication0.0000.000
Open science0.0000.000
Research integrity0.0000.001
Insufficient payload (model declined to judge)0.0010.000

Machine scores (provisional)

The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.

Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.

Opus teacher head0.231
GPT teacher head0.553
Teacher spread0.322 · how far apart the two teachers sit on this one work
Validation statusscore_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from it