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Medical Error and Patient Safety


Medical error and patient safety are critical factors in clinical medicine since they play an important role in enhancing care delivery and patient outcomes (Barach, 2000). In this respect, this paper will critically analyze the work presented by Woolever (2001) titled ‘The Impact of a Patient Safety Program on Medical Error Reporting’. To critically analyze this article, this paper will focus on the problem statement, study purpose, research questions, literature review, and theoretical framework to determine the role played by each of these segments in developing, analyzing, and enhancing the research topic using a qualitative approach.

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Problem Statement

By critically analyzing the current study, it is evident that this paper was developed in response to the sentinel event. The sentinel event was a serious medical error event that resulted in serious consequences in terms of the death of unexpected injury that occurred at the Elgin US Air Force (USAF) Regional Hospital. Even though several approaches and systems have been developed to report and further investigate these occurrences, the author has asserted that death and permanent injuries have still been reported. He attributes these trends to the use of outdated systems that require every sentinel event to be reported and filed, analyzed, its trends identified and recommendations made.

Given the rise in media demands and an increase in public awareness of medical errors, the author saw that it was imminent for medical practitioners to come up with an effective and efficient system that will not only enhance the reporting of sentinel events but will also minimize medical errors as well as enhancing patient safety. It is as a result of this fact the Medical Team Management (MTM) system was developed by a working group of the US Air Force Regional Hospital in Elgin. With this new system, the hospital is expected to greatly reduce medical errors thus minimizing the risks of death and permanent injury that might arise as a result of a sentinel event.

This study is thus significant in itself because it aims at critically analyzing the effectiveness and efficiency of the MTM system in enhancing teamwork among hospital personnel in the identification and reporting of medical errors. The fact that this system includes all members of staff in the reporting of such errors greatly eliminates any form of miscommunication in reporting hence resulting in the delivery of effective and efficient medical services.

Purpose and Research Questions

Given the drawbacks of traditional methods of reporting errors and the development of the MTM system of error reporting, the purpose of this research study was to evaluate the success of the MTM system to avoid sentinel events. To achieve this, the author compared the rates of error reporting before and after the implementation of MTM. Any difference that might result from this comparison will be attributed to the application of the MTM system in error reporting. In any study, a clear and direct purpose is critical in developing the hypothesis of the study at hand, generating research questions, research methods, and the theoretical framework.

Given the problems and challenges experienced by USAF Regional Hospital in Elgin, it is hypothesized that the application of the MTM system will reduce the frequency of error reporting within the healthcare facility. This will come about as a result of improved communication within the facility and the elimination of blame in error reporting. As such, there will be a decline in the severity of incidences as well as patient outcomes within the hospital.

From a critical point of view, the author of this paper did not come up with clear-cut research questions. However, based on its context, the following research questions are evident:

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  1. Are there differences in error reporting before and after the implementation of MTM?
  2. Which members of the healthcare team are actively involved in the filing of reports?
  3. What are the trends of the severity of incidences and bad patient outcomes before and after the implementation of MTM?
  4. What impacts does the MTM system have in the aversion of error reporting and patient outcomes within the healthcare industry?

From a critical point of view, it is evident that the purpose of this study and the research questions that have been listed above have a high rate of correlation. As asserted earlier, the purpose of this study was to determine the effectiveness and efficiency of the MTM system as a tool of error reporting to reduce sentinel events. The research question on the other hand focus on reporting trends before and after the implementation of MTM, the role of communication in reporting, and the impact of the system in reducing medical errors and patient outcomes. Given the study hypothesis and the research question, this study followed a qualitative approach that effectively answered the research questions.

Literature Review

A literature review is an essential part of a research paper. Through the literature review, authors can come up with information regarding the information that is currently available on the research topic. In this study, for instance, the author cited a mixture of qualitative and quantitative studies to support his purpose. For instance, the paper by Bates, O’Neil, and Boyle (1994) and Risser, Rice, and Salisbury (1999) that focused on adverse effects of reporting and improvement of medical error reporting are the examples of qualitative studies that the author used in his literature review to support his purpose and research aim. Additionally, the author did use secondary sources of information such as books to further support his arguments in his literature review. However, most of the references in this paper appear to be older than 5 years from the date of publication of this paper and hence they are not recent. Additionally, the author did not critically analyze the strength and weaknesses of his references. Despite this fact, the sources that have been used in this paper are highly valid and proved to be helpful to the author in supporting his arguments all through his paper.

Theoretical Framework

In this study, the author did not expressly identify the specific perspective from which the study was developed. However, by critically analyzing the paper, it is evident that there are several variables that he intended to measure and relationships that he needed to understand hence building a base of his purpose for the study. This includes variables such as reports of incidences over time to determine the trends of incidents reports and the number of personnel filing these reports. Finally, the author wanted to establish the compare the differences in error reporting before and after the implementation of MTM. However, the author did not develop a framework from the findings of the study.


Barach, P. (2000). Patient Safety Curriculum. London: Sage.

Bates, D., O’Neil A., & Boyle, D. (1994). Potential identifiability and preventability of adverse events using information systems. JAMIA, 1(1): 404–11.

Risser, D., Rice, M., & Salisbury, M. (1999). The potential for improved teamwork to reduce medical errors in the emergency department. JSTOR, 343(1): 373–83.

Woolever, D. (2001). The Impact of a Patient Safety Program on Medical Error Reporting. Advances in Patient Safety, 1(1): 307-16.

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