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In a recent study, 7 percent of infants arriving at the emergency room with a high fever were treated inappropriately. Either they were given antibiotics they didn't need or they did not receive antibiotics they needed, even though doctors followed a strict protocol for identifying high-risk infants with serious bacterial infections.
If a protocol designated 75 percent of a hypothetical group of 10,000 febrile infants high-risk, misclassifying 7 percent would lead to 525 high-risk infants not receiving antibiotics. Of the remaining 2,500 low-risk infants, 175 would be hospitalized and treated unnecessarily. Finally, if 10 percent of febrile infants have a serious bacterial infection, misclassifying 7 percent would leave 70 infected infants untreated. Harm to at least some infants would be nearly inevitable, explain Donald A. Goldmann, M.D., of Children's Hospital, Boston, and colleagues, in a recent commentary.
Dr. Goldman and colleagues assert that despite protocols, medical errors are intrinsic to complex systems. Old-style peer review and quality assurance programs attempt to reduce error by increasing physician vigilance and identifying physician outliers (those who make the most mistakes). However, there were no outliers in the study of febrile infants; errors were evenly distributed among 13 of the 18 emergency department physicians. Also, physicians correctly treated 93 percent of patients, which indicates a level of diligence and expertise unlikely to be augmented by greater effort.
The researchers assert that the 7 percent failure rate is a function of the system of care, not of individual vigilance or motivation. They note that for the other 7 percent of patients to enjoy the therapeutic benefits of the protocol, systems must be redesigned to anticipate and avert cognitive errors, which are an expected by-product of any human process.
For more information, see "Reducing medical error through systems improvement: The management of febrile infants," by James Glauber, M.D., Dr. Goldmann, Charles J. Homer, M.D., M.P.H., and Donald M. Berwick, M.D., M.P.P., in the June 2000 Pediatrics 105(6), pp. 1330-1332.
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