There is, however, little research on the incidence of WPEs in otolaryngology. In 2014, Rahul K. Shah, MD, MBA, a professor of otolaryngology and pediatrics at George Washington University School of Medicine and Health Sciences and vice president and chief quality and safety officer at the Children’s National Health System in Washington, D.C., and his colleagues surveyed members of the American Academy of Otolaryngology–Head and Neck Surgery (AAO–HNS). Of the 681 responders, 445 (66%) reported an event that shouldn’t have happened in the prior six months, from which 222 reports were extracted. The investigators identified adverse consequences in half of the events; corrective actions were reported in 82.8%. Practice pattern changes were instituted 68% of the time (Otolaryngol Head Neck Surg. 2014;150:779–784).
Dr. Shah also said that otolaryngologists are especially vulnerable to WPEs due to the wide variety of settings in which they see patients.
Multiple Environments, Multiple Systems
An additional problem is that many physicians practice in multiple environments. They spend the morning in clinic, the afternoon performing outpatient surgery, and the evening rounding on inpatients. Despite attempts at interoperability, most have their own electronic medical record (EMR) systems.
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