Since the publication of the Institute of Medicine’s report, To Err is Human,1 accumulating data have shown that patient safety systems are slowly improving. There is greater recognition of patient safety in the medical literature and more monetary awards for research regarding medical errors.2 Most quality improvement experts call for an acceleration of progress in order to meet the goals set out by institutions and organizations across medical specialties.3-8
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November 2006In otolaryngology, Roberson et al. expressed to their colleagues that there is a well-defined body of knowledge that substantiates there is a minimum human error rate that can never be eliminated, and therefore, gaining a better understanding of systems-science principles can help clinicians provide better and safer care.9
How does otolaryngology differ from medical practice, general surgery, or other surgical subspecialties when it comes to medical errors? This question was posed at the heart of research conducted in the past five years by a team including Rahul K. Shah, MD; David W. Roberson, MD; and Gerald B. Healy, MD, at Boston Children’s Hospital.10,11 Dr. Shah, now with the Division of Otolaryngology at Children’s National Medical Center in Washington, DC, said that Dovey and Elder’s landmark work developing a taxonomy for medical errors in family practice12,13 was the inspiration for their research team when they subjected their specialty to the medical-error microscope.