What are the causes of Medical Stiches?

Medical Errors

• I'm doing a talk on medical errors and how training medical students and doctors through simulations (standardized patients and robotics) may prevent medical errors. So I have a couple related questions: What are the major causes of medical errors (in any medical setting)? Are there training programs (for example but not limited to using patient simulations) at the medical student and / or at the physician level) that have been proven to reduce or prevent medical errors?

• Answer:

  Hello, modiano-ga! Well, a question that I thought would be relatively easy to answer proved to be surprisingly tough! I presumed there would be a readily available list of the top medical errors, but there was nothing of the sort. I also assumed there would be numerous studies showing the efficacy of simulated training and the proven reduction of medical errors in the clinical setting. There were only two! There was a wealth of information pertaining to the existence of medical errors as a very serious problem. But, when it came to identifying the major causes of medical error, it was a matter of piecing information together from numerous sources. There was also no shortage of information pertaining to training programs for medical students and physicians, including simulated surgery, videotaping of mock procedures, etc. While the research suggests that medical personnel learned from, valued the training and posted positive results on the simulator, there was little information regarding the carryover of results into an actual medical setting. In other words, I could find no studies that stated, for example - "twenty physicians trained on the cardiovascular surgical simulator, performed brilliantly, and five years later, those same physicians have seen a x% reduction in medical errors." Only two studies recorded reduced clinical errors. I don't know if this information is a positive revelation for you or not. At the very least, it points to the need for follow-up studies to prove that various types of simulated training can have a positive carryover into the medical setting. ======================== DEFINING MEDICAL ERRORS ======================== "The IOM defines medical error as "the failure to complete a planned action as intended or the use of a wrong plan to achieve an aim." An adverse event is defined as "an injury caused by medical management rather than by the underlying disease or condition of the patient." Some adverse events are not preventable and they reflect the risk associated with treatment, such as a life-threatening allergic reaction to a drug when the patient had no known allergies to it. However, the patient who receives an antibiotic to which he or she is known to be allergic, goes into anaphylactic shock, and dies, represents a preventable adverse event." "Most people believe that medical errors usually involve drugs, such as a patient getting the wrong prescription or dosage, or mishandled surgeries, such as amputation of the wrong limb. However, there are many other types of medical errors, including: * Diagnostic error, such as misdiagnosis leading to an incorrect choice of therapy, failure to use an indicated diagnostic test, misinterpretation of test results, and failure to act on abnormal results. * Equipment failure, such as defibrillators with dead batteries or intravenous pumps whose valves are easily dislodged or bumped, causing increased doses of medication over too short a period. * Infections, such as nosocomial and post-surgical wound infections. * Blood transfusion-related injuries, such as giving a patient the blood of the incorrect type. * Misinterpretation of other medical orders, such as failing to give a patient a salt-free meal, as ordered by a physician. From "Medical Errors: The Scope of the Problem. Fact sheet, Publication No. AHRQ 00-P037. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/qual/errback.htm === "The human cost of medical errors is high. Based on the findings of one major study, medical errors kill some 44,000 people in U.S. hospitals each year. Another study puts the number much higher, at 98,000. Even using the lower estimate, more people die from medical mistakes each year than from highway accidents, breast cancer, or AIDS. Moreover, while errors may be more easily detected in hospitals, they afflict every health care setting: day-surgery and outpatient clinics, retail pharmacies, nursing homes, as well as home care. Deaths from medication errors that take place both in and out of hospitals - more than 7,000 annually - exceed those from workplace injuries." From "Preventing Death and Injury From Medical Errors Requires Dramatic, System-Wide Changes." National Academies (1999) http://www4.nationalacademies.org/news.nsf/isbn/0309068371?OpenDocument ===================================== GENERAL INFORMATION ON TYPE OF ERRORS ===================================== "In a recent overview of 11 studies on the frequency and nature of medical errors in primary care, medical error rates ranged from 5 to 80 errors per 100,000 visits. Errors related to delayed or missed diagnosis were most common, ranging from 26% to 78% of identified errors. Treatment errors comprised the second most common category, accounting for 11% to 42% of identified errors. The causes of these errors were often multiple and remained unidentified in up to 50% of cases. The marked diversity in the findings reflected the varied definitions of errors and methods of detection." "A recent study of US family practitioners that was designed to develop a taxonomy of errors that are likely to occur in primary care practices gives an idea of the relative frequencies of different types of errors) Forty-two physicians voluntarily provided 344 error reports. Of these, 330 were deemed true errors; 72 occurred in the outpatient setting. Most errors were due to errors in lab or testing processes (27% information management or charting (23%), medication therapy (18%), and knowledge errors on the part of the physician (13%). The physicians reported that 44% of their errors led to adverse events, including 1 death. A similar study of a multinational group of general practitioners had similar results." From "Reducing medical errors in primary care: medical errors come in all shapes and sizes and stem from a variety of causes," by Craig R. Keenan, Kwabena Adubofour, Ashok V. Daftary. Patient Care, (Dec, 2003) http://216.239.53.104/search?q=cache:UAfCe7O-MgwJ:www.findarticles.com/cf_dls/m3233/12_37/112314608/p1/article.jhtml+Medical+training+to+reduce+errors&hl=en (This is a "cached" link. If it is not highlighted in my answer, simply copy and paste the URL into your browser to read the full article) === A report from the Robert Graham Center analyzed more than 50,000 claims from the Physician Insurers Association of America malpractice claims database. The results highlight the following: * "The research focuses on the actual location where people are most frequently harmed: the outpatient setting, not in hospitals." Another Overview of Causes ============================ "The JOURNAL of the AMERICAN MEDICAL ASSOCIATION (JAMA) Vol 284, No 4, July 26th 2000 article written by Dr Barbara Starfield, MD, MPH, of the Johns Hopkins School of Hygiene and Public Health, shows that medical errors may be the third leading cause of death in the United States. The report apparently shows there are: 2,000 deaths/year from unnecessary surgery; 7,000 deaths/year from medication errors in hospitals; 20,000 deaths/year from other errors in hospitals; 80,000 deaths/year from infections in hospitals; 106,000 deaths/year from non-error, adverse effects of medications these total up to 225,000 deaths per year in the US from iatrogenic causes which ranks these deaths as the # 3 killer. Iatrogenic is a term used when a patient dies as a direct result of treatments by a physician, whether it is from misdiagnosis of the ailment or from adverse drug reactions used to treat the illness. (drug reactions are the most common cause)." From the CancerCure website: http://www.cancure.org/medical_errors.htm =================== DIAGNOSTIC ERRORS =================== * "Diagnostic errors accounted for more than one-third of the claims." "The underlying cause "diagnostic error" alone accounted for over one-third of claims. The category "diagnostic error" doesn't give us enough information to fix the problems. This category is most likely not about bad doctors and more likely about doctors making decisions with poor support systems and information. "For example, it doesn't tell us whether the wrong diagnoses resulted from a lab report that did not reach the physician, a consultant note filed in the wrong patient's chart or if the physician made the wrong decision that could have been avoided with better training." ================= RECORDS PROBLEMS ================= "Problems with records" was associated with errors that hurt a lot of people, and these harms were fairly evenly distributed across the outcome severity categories (low, moderate and high severity, and death). ====================================== FAULTY COMMUNICATION BETWEEN PROVIDERS ======================================= "Problems with "communication between providers" contributed to more high severity outcomes and death. How your doctor is equipped to manage your medical records and talk with other doctors can protect you from errors. These two contributing factors suggest that frequent errors in primary care that are thought to be trivial can contribute to bad health outcomes for patients and should not be ignored." From "Outside View: To prevent medical errors," by Dr. Robert L. Phillips Jr. United Press International. (April 2, 2004) http://washingtontimes.com/upi-breaking/20040401-041120-3279r.htm and "Malpractice Claim Reports Can Help Direct Prevention of Medical Errors, Study Says." American Academy of Family Physician. April 1, 2004 http://www.aafp.org/x26865.xml ======================= DRUG/MEDICATION ERRORS ======================= "Drugs have been found to be among the most common causes of medical injury. In the Harvard study, 19.4 percent of the injuries detected were related to the use of drugs, while the Andrews study determined that 9.3 percent of injuries were medication-related." From "Medical Error and Patient Injury: Costly and Often Preventable." AARP Research. http://216.239.57.104/search?q=cache:bfzbgWKdRoUJ:research.aarp.org/health/ib35_medical_1.html+major+causes+of+medical+errors&hl=en (to access this article, please copy and paste the article title and click on the "cached" version, or copy and paste the URL into your browser) ============= SYSTEM FLAWS ============= "The majority of medical errors do not result from individual recklessness, the report says, but from basic flaws in the way the health system is organized. Stocking patient-care units in hospitals, for example, with certain full-strength drugs - even though they are toxic unless diluted - has resulted in deadly mistakes. And illegible writing in medical records has resulted in administration of a drug for which the patient has a known allergy." From "Preventing Death and Injury From Medical Errors Requires Dramatic, System-Wide Changes." National Academies (1999) http://www4.nationalacademies.org/news.nsf/isbn/0309068371?OpenDocument == "Findings from several studies of large numbers of hospitalized patients indicate that each year a million or more people are injured and as many as 100,000 die as a result of errors in their care." "..errors are seldom due to carelessness or lack of trying hard enough. More commonly, errors are caused by faulty systems, processes and conditions that lead people to make mistakes. They can be prevented by designing systems that make it hard for people to do something wrong and easy to do it right." From "CONCERNING PATIENT SAFETY AND MEDICAL ERRORS." Statement by Lucian Leape, M.D. before the Committee on Health, Education, Labor and Pensions. U.S. Senate (1/25/2000) http://www4.nationalacademies.org/ocga/testimon.nsf/0/7855d392199e399685256873006dd790?OpenDocument =================== INADEQUATE STAFFING =================== "More than one-third of practicing physicians and 40 percent of the public say they or a family member have experienced a medical error, according to a survey reported Dec. 12 in the New England Journal of Medicine. And, while the two groups diverged on possible causes and solutions, both ranked shortages of nurses; and overwork, stress and fatigue among health care workers as "very important" causes of errors." "Specifically, the survey found that more than 53 percent of physicians and 65 percent of the public cited understaffing of nursing in hospitals as a factor in errors, while 50 percent and 70 percent of physicians and the public, respectfully, blamed errors on overworked, stressed or fatigued health care workers. The survey was conducted last spring by researchers at the Henry J. Kaiser Family Foundation and the Harvard School of Public Health." "This study provides more evidence of the impact of nurses' working conditions on patients," said ANA President Barbara Blakeney, MS, APRN,BC, ANP. "The results point to the fact that medical mistakes are common and that both physicians and the public see inadequate nurse staffing as a significant cause of errors." From "Harvard University Study Identifies Inadequate Nurse Staffing as A Major Factor in Medical Errors." American Nurses Association. (Dec. 16, 2002) http://www.nursingworld.org/pressrel/2002/pr1216.htm Additional Information ====================== You might want to order the following books if you have time before your presentation: "Medical Error: What Do We Know? What Do We Do Now? http://www.med.umich.edu/opm/newspage/2002/medbook.htm (see ordering information at bottom of article) "Internal Bleeding: The Truth Behind America's Terrifying Epidemic of Medical Mistakes," by Robert Wachter and Kaveh Shojania http://www.book.nu/1590710169 ================== TRAINING PROGRAMS ================== Though there is a lot of information on medical training (primarily medical simulation) there is very little published on the results as applied to reduced medical errors. I found only one study that actually mentioned a reduction of medical errors. One other study revealed a marked increase in confidence of personnel conducting medical trials. Positive Results from the MedTeam Training Curriculum ======================================================= "The MedTeams curriculum teaches behaviors that are applicable to the healthcare workplace and are anchored in real world problems. The core of the training is 41 well-defined behaviors that constitute the process of teamwork. The training takes 8 hours, and is augmented by a video depicting examples of good and poor teamwork, practical exercises, and discussion. Practicums, coaching, mentoring, and teamwork review sessions subsequently take place in the emergency department to further instruct and reinforce teamwork behaviors in the operational setting." "But for now, let me turn to the impact of our training on events in the ER. We conducted an experiment involving nine teaching and community hospitals divided into experimental and control groups.5 The experimental group received the MedTeams training. The control group allowed us to evaluate improvements occurring in the experimental group. Three outcome constructs were assessed: team behaviors, attitudes and opinions, and ED performance. Improvements were obtained in the experimental group for six out of the seven key measures assessed. The quality of team behaviors improved, workload was not increased by practicing teamwork, staff attitudes towards teamwork were enhanced, preparation of patients admitted from the ER improved, and the proportion of highly satisfied patients increased." ** The most important finding from the validation was that clinical errors were substantially and significantly reduced. A clinical error was defined as any clinical task that actually or potentially put a patient at risk. These errors were witnessed by a specially trained ER nurse or physician observing cases for the purpose of rating teamwork behaviors. " An example of a reported error occurred during a resuscitation. A burn patient received duplicate administrations of intravenous morphine when two nurses independently administered the drug after a physician gave a verbal order. The staff recognized the overdose when the patient's breathing slowed, at which point they intervened and the patient recovered. A check-back for a verbal medical order, a teamwork behavior taught in MedTeams, would have avoided or "captured" this error." Read "Panel 2: Broad-based Systems Approaches - Creating Complementary Roles for Behavioral Solutions and Technology Applications to Patient Safety." Testimony of Robert L Wears, MD, MS, Department of Emergency Medicine University of Florida; Robert Simon, EdD, CPE, Chief Scientist, Crew Performance Group, Dynamics Research Corporation; and the MedTeams Consortium* (Sept 2000) http://www.quic.gov/summit/wwears.htm Simulated sigmoidoscopy result in fewer directional errors on actual patients =============================================================================== "In a small randomized controlled trial enrolling 10 residents, Tuggy and colleagues found residents who trained for flexible sigmoidoscopy using a virtual reality simulator were faster, visualized a greater portion of the colon, and made fewer directional errors in actual patients. From "Chapter 45: Simulator-Based Training and Patient Safety." http://www.ahrq.gov/clinic/ptsafety/pdf/chap45.pdf Increased Confidence in Clinical Trial Setting after Simulation Training ========================================================================= "Duke University Medical Center researchers have demonstrated that training research coordinators on a human simulator prior to a complex clinical trial can significantly improve the coordinators' confidence in their abilities. Since the researchers believe that confidence is a central element in competence, they said that the routine use of such simulators could not only lead to the collection of higher quality data during a trial, but can also have an important impact on improving patient safety." "According to Taekman, when ranked on a scale of one to ten, with ten being the most confident, the coordinators who participated saw their overall average confidence score increase from 5.7 to 8.12." "While all three domains of learning saw dramatic increases after simulator training, the psychomotor area saw the greatest relative improvement, from 4.83 to 8.1. The affective domain increased from 6.13 to 8.17 and the cognitive domain increased from 6.17 to 8.03." "We fully believe that simulation training could be the wave of the future, especially after seeing the results of this study," Taekman said. "The current approach to training coordinators fails to take advantage of adult learning theory, which has shown that interactivity is a superior method for teaching medical professionals." "In terms of the learning process, the simulator provides the next best thing than actually being at the bedside." Taekman continued. "The simulator allows learners to hone their skills before coming in contact with patients, thereby shortening the learning curve." From "Patient Simulator Improves Performance Of Clinical Trial Coordinators. Duke Med News. (10/14/2003) http://dukemednews.duke.edu/news/article.php?id=7099 Patient Safety Team Training points to potential for reduced clinical errors ============================================================================ "VHA offers its member hospitals Patient Safety Team Training, a product focused on improving patient safety, patient satisfaction, and performance in the emergency or labor delivery departments. VHA's Patient Safety Team Training uses proven methods based on aviation crew resource management techniques employed in that industry. Grounded in two decades of research and development, this training process was evaluated at 12 leading health care organizations over two years. ** Effectiveness results included fewer observed clinical errors, minimized litigation costs, and enhanced ability to achieve compliance with patient safety standards of the Joint Commission for Accreditation of Healthcare Organizations as well as with the IOM's 1999 patient safety recommendations." (I could find no documentation for the above statement on reduced clinical errors) "Under this program, a VHA physician and nurse who have expertise in team training implementation in the high-performance, high-stress care environment first conduct an on-site assessment of an organization?s readiness. They then conduct "train the trainer"sessions where select physicians and nurses in the organization learn to present the core curriculum to all staff members, bring about a culture change in their department, and reinforce team work behaviors using facilitated leadership and coaching." From "Reducing Medical Errors: A Review of Innovative Strategies to Improve Patient Safety." Subcommittee on Health. (May 8, 2002) http://energycommerce.house.gov/107/hearings/05082002Hearing557/Freeman955.htm Simulation studies which demonstrate improved skills, but do not measure error reduction in the medical setting: =============================================================================== Background: "We initiated a teaching module utilizing a human simulator midway through 2001-2002 to improve student skills specific to the evaluation of patients in shock during a required clerkship in surgery for 4th year medical students. We tested the hypothesis that student skills would improve after implementation of this module and identified factors that predicted student performance." Conclusion: "In a clerkship that already emphasized faculty facilitated case-based learning, the use of a teaching module employing a human simulator significantly improved test scores. This study supports the efficacy of human simulators to improve student skills related to the management of complex critically ill patients." From "Effective Use of Human Simulators in Surgical Education," by Mordechai Bermann, MD UMDNJ (2003) http://www.anestech.org/Publications/IMMS_2003/sta46.html === Introduction: "To date, few studies have attempted to quantify human performance during simulation training. This study used training evaluation from the applied psychology literature to assess the effectiveness of simulator training in increasing residents performance. We examined residents level of confidence, knowledge, attitudes and performance during a 3-day pre-clinical simulator course. The variables have been identified as critical indices of effectiveness in training intervention." Results: "Subjects responses were analyzed to examine changes in residents levels of confidence, knowledge, and reactions as a function of time on the simulator. Residents level of confidence on trained tasks increased dramatically, while confidence in non-trained tasks remained steady. Knowledge test results showed an increase in the residents scores and an increased level in knowledge for trained tasks. Trainees were highly motivated. They perceived the simulator training to be extremely useful. Additionally, residents wished to have further simulator training. Finally, evaluation of the videotaped scenarios showed that residents recognition skills and critical decision making improved while reaction time and number of errors were reduced." From "Increasing Performance Through Simulator Training and Empirical Evaluation," by Harold Doerr, M.D., Miquel A. Quinones1, Ph.D., Robert L. Dipboye1, Ph.D., Burdett a Dunbar,M.D. http://www.anestech.org/Publications/Annual_2000/Doerr.html == "As part of an ongoing study at Rush Presbyterian St. Luke's Medical Center, residents who practised sigmoidoscopies on Immersion Medical's simulators demonstrated a statistically significant 75 percent increase in overall competency scores. This study validates the use of Immersion Medical's AccuTouch Endoscopy Simulator with Flexible Sigmoidoscopy module in reducing the number of patient-based procedures required to achieve competency in performing flexible sigmoidoscopy. A gastro-enterologist objectively scored the residents, monitoring factors such as intubation, retroflexion, pathology, and virtual patient discomfort." "This study validates the use of medical simulators for training doctors in conducting minimally invasive surgeries", stated Dr. Michael Brown of Rush Presbyterian St. Luke's Medical Center. "Immersion Medical's simulators are a more effective way of training than the traditional methods, allowing residents to repeat difficult procedures until they feel comfortable. Reducing the number of procedure-related errors during the learning process translates into safer patient care. This technology will have profound effects in improving health care education at all levels." From "Study proves medical simulators reduce number of patient-based procedures required to learn endoscopy skills." Virtual Medical World. (Dec. 2002) http://www.hoise.com/vmw/03/articles/vmw/LV-VM-01-03-8.html === Medical students displayed greater detection of breast tumors in the dynamic, variable-lump, silicone breast simulator after training. However, there is still a need for this type of training to display a transfer of results to the clinical setting. "DYNAMIC SIMULATOR FOR TRAINING CLINICAL BREAST EXAMINATION Gregory J. Gerling, Geb W. Thomas, Alicia M. Weissman, Edwin L. Dove http://grok.ecn.uiowa.edu/Main/Publications/HFES_02_Final.pdf === Stanford has implemented a number of simulation training programs, which are described below. Unfortunately, there is no follow-up data on whether these programs have actually reduced errors in the medical setting. If you have time, you might want to call the Director of the Center and ask if they have compiled any data: David M. Gaba, M.D Patient Safety Center of Inquiry (PSCI) Anesthesia Service, 112A VA Palo Alto Health Care System 3801 Miranda Avenue Palo Alto, CA 94304 Voice: (650) 858 3938 Fax: (650) 849-0421 Email: [email protected] "Simulation Center for Crisis Management Training in Health Care - VA Palo Alto Health Care System & Stanford University." http://anesthesia.stanford.edu/VASimulator/ The Simulation Center: http://anesthesia.stanford.edu/VASimulator/simcntr.htm Anesthesia Crisis Resource Management (ACRM) http://anesthesia.stanford.edu/VASimulator/acrm.htm Criteria for ACRM-like Training http://anesthesia.stanford.edu/VASimulator/ACRM_Criteria.htm The Simulated Delivery Room (SDR) http://anesthesia.stanford.edu/VASimulator/SDRE.htm The MedSim-Eagle Patient Simulator http://anesthesia.stanford.edu/VASimulator/sim.htm Other types of Training (with no documentation of decrease error in the field) ======================== "Another way to enhance patient safety through early identification is by implementing disease management programs. We have comprehensive disease management programs in place for asthma, diabetes, high-risk pregnancies and cardiovascular disease. In these programs, an engagement model is used to contact all members affected by the disease and help them manage their condition better. In these programs, all patients are entered into a tracking database, which allows us to develop error prevention information. * Physicians receive training on best practices through problem-based learning techniques, which is a familiar and accepted mode of learning. * "Outcomes to date for our asthma program show improved use of appropriate medication and reduced emergency rooms use. In patients with diabetes, the appropriate number of HgA1c tests are being ordered and that members are getting the appropriate exams for feet, eyes, etc." From "HMSA's Program to Improve the Quality of Health Care by Reducing Medical Errors and Increasing Patient Safety." http://www.hmsa.com/about/quality/patient_safety.asp == Enhancing Communication Skills between physicians and patients is touted as a method to reduce medical errors. However, there is no mention of programs or outcome results. From "Enhanced communication to reduce liability," by James W. Saxton, Esq. & Maggie M. Finkelstein, Esq. Physicians News Digest. Published November 2003 http://www.physiciansnews.com/business/1103saxton.html === "Diagnostic errors are the most difficult to prevent, and the most devastating, according to Dr. Croskerry. Drawing on his psychology background (a field in which he obtained a PhD before entering medicine), Dr. Croskerry has developed a two-hour course for medical students that has become part of the "Introduction to Clerkship" program. Called Applied Cognitive Training in Acute Care Medicine, the course teaches students how to be aware of their own thinking as they approach a patient, and gives strategies for avoiding errors. Dalhousie is the first medical school to introduce such a course, though Dr. Croskerry hopes it will soon be standard across North America." From "Symposium Part of Larger Effort to Address Medical Error." Connection. October/November 2001, Vol.8, No.6 http://communications.medicine.dal.ca/connection/junejuly2002/conn20027k.htm SIMULATED TRAINING DOESN'T ALWAYS TRANSFER TO INCREASED COMPETENCY IN THE FIELD =============================================================================== "Proficiency on a simulator does not ensure proficiency in clinical settings. Simulator fidelity (ie, how accurately the simulator replicates reality) is imperfect. It is much more difficult to "re-create" a human being than to do so for, say, an airplane. This limitation is illustrated by a study conducted by Sayre and colleagues. They studied emergency medical technicians (EMT) who learned intubation techniques on anesthesia mannequins. After successfully intubating the mannequins 10 times, they were permitted to intubate patients in the field, where their proficiency was only 53%. Other factors can inhibit optimum learning using simulation or the applicability of learning to real practice. Other factors can inhibit optimum learning using simulation or the applicability of learning to real practice. Some participants may be more vigilant than usual during simulator sessions. Others may be unable to "suspend disbelief," may treat the simulationonly as a game, or act in a cavalier fashion, knowing that the simulator is not a real patient. Refinement of simulators to make them more sophisticated and life-like may help to improve the quality of the training that simulators can provide." From "Chapter 45: Simulator-Based Training and Patient Safety." http://www.ahrq.gov/clinic/ptsafety/pdf/chap45.pdf ADDITIONAL READING =================== A host of links to Simulation Articles: (which I cannot access) http://www.harvardmedsim.org/Simulation%20references.htm "Reducing Medical Errors: A Review of Innovative Strategies to Improve Patient Safety." Subcommittee on Health (May 8, 2002) http://energycommerce.house.gov/107/hearings/05082002Hearing557/print.htm "Virtual training to reduce surgical errors." The Age (April 11 2003) http://www.theage.com.au/articles/2003/04/11/1049567857521.html "Chapter 2. Efforts to Reduce Medical Errors: AHRQ's Response to Senate Committee on Appropriations Questions." http://www.ahrq.gov/qual/pscongrpt/psini2.htm == I hope the information I have provided is useful. If it turns out that I took your request about proven results too literally, and you are happy with positive results before and after using a simulator (but not necessarily in the clinical setting), please let me know and I will certainly add more references. I came across many such reports, but did not include them because they did not apply to real life situations. As usual, if you have need for further clarification of any sort, please don't hesitate to ask. I will be happy to help if I can! Sincerely, umiat Search Strategy major causes of medical errors top medical mistakes training to avoid medical mistakes training physicians to avoid medical errors training to avoid medical mistakes patient simulation and error prevention does medical simulation reduce errors? 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