After an initial medical misadventure, failure of recognition and continuing factors that could perpetuate the error are examined.
A critical evaluation of the continuum of care after the initial error was conducted through chart review and comparison to published standards.
Analysis of the continuum of care after the original error demonstrated numerous system failures that should have alerted the providers to the initial error.
Technology, electronic medical records, lack of critical communications, and short cuts have the potential to not recognize patient care safety issues and potential harm.
Medical errors are multifactorial. Blame casting and accusations are not productive. Critical analysis of systems/processes, current technology, eliminating shortcuts, and critical communications may increase patient safety.