ABSTRACT
Errors and near-misses occur frequently in clinical practice. In a widely reported study (Brennan et al. 1991), it was estimated that injuries caused by human errors occurred in 2.5% of admissions to participating hospitals in an acute care setting. In another study (Wilson et al. 1995), it was judged that 8.3% of admissions were associated with highly preventable adverse events in the healthcare management of patients resulting in disability or a longer hospital stay. It should be noted that in both studies, the method to estimate these frequencies was to screen a large number of medical records and analyze those records meeting certain criteria more extensively to conclude that an iatrogenic injury had occurred. None of these studies based the estimated occurrence frequency on reports of errors and near-misses. Signicant dierence in frequency between specialties was reported in the second study, for example, three times as many adverse events in cardiac surgery as in medical oncology. While radiotherapy was not one of the specialties reported on, other studies have indicated that errors and near-misses also occur frequently here (Holmberg and McClean 2002; Huang et al. 2005; Yeung et al. 2005).
