Errors and adverse events in otolaryngology.

PURPOSE OF REVIEW

The study of errors in medicine has proliferated in the past few years. This spark was ignited by the Institute of Medicine's report in 2000, titled 'To Err is Human'. Studies of errors have been performed in both medical and surgical specialties. Surgical skill and technology has proliferated over the last century to such an extent that outcomes will probably not improve from focusing finite resources on attempts to enhance surgical skill or developing new instrumentation. Advancing medicine in the 21 Century will probably depend on our ability to address and ameliorate errors and adverse events in healthcare. Directing attention to this previously little studied realm of medicine has the ability to dramatically reduce morbidity and mortality. Small changes have the ability to result in outcomes that are far beyond what is predicted by incremental measures.

RECENT FINDINGS

There have been studies identifying and classifying errors in otolaryngology in out-patient and in-hospital settings, addressing allergy sera misadministration, providing quality assurance for pathology reports in head and neck malignancies, implementing computerized patient records, and detailing problems that occur when patients have a test ordered and the results are not followed up.

SUMMARY

The study of errors in medicine is going to dramatically increase in the next decade. The practicing otolaryngologist must be vigilant for errors, use surgical time-outs, should have a system in place to track tests ordered and results received, and most importantly have the capability to identify and ameliorate errors as they occur on an individual and institutional level.