Trends in Medical Error Education: Are We Failing Our Residents?

Trends in Medical Error Education: Are We Failing Our Residents? Corey K. Bradley, BA; Melissa A. Fischer, MD, MEd; Kathleen E. Walsh, MD, MSc From the Davidson College, Davidson, NC (Ms Bradley); Department of Medicine (Dr Fischer), and Department of Pediatrics (Dr Walsh), University of Massachusetts Medical School, Worcester, Mass Address correspondence to Kathleen E. Walsh, MD, MSc, Department of Pediatrics, Benedict Second Floor, UMass Medical Center, 55 N Lake St, Worcester, MA 01655 (e-mail: walshk02@ummhc.org). Received for publication January 26, 2012; accepted October 11, 2012. ABSTRACT BACKGROUND: The Institute of Medicine has called for physician education as a key step in medical error prevention. In our 2002 national survey, pediatric resident education about medical error prevention was sporadic. We sought to describe the amount and type of pediatric resident training about medical errors and to assess the change in training since 2002. METHODS: We surveyed a national sample of 50 pediatric chief residents randomly selected from the 198 Accreditation Council for Graduate Medical Education accredited residency programs from August to November 2010. The 31-item telephone survey was developed from the 2002 survey, with the addition of 10 items about electronic learning and resident quality improvement projects. The survey included 4 domains: current patient safety curriculum, chief resident knowledge, learning from medical errors, and demographics. RESULTS: We phoned 55 chief residents and contacted 51. Fifty participated (90% participation rate). Ninety-four percent of chief residents stated that their program had a formalized curriculum to discuss medical errors, compared to only 50% (P <.001) in 2002. Ninety-six percent understood that the response to a medical error should be systemic change. The primary method for educating residents about medical error reported was informal teaching. Ninety-two percent reported never or rarely discussing medical error in an outpatient setting. Seventy-four percent of chief residents reported that they never or rarely learn from an error made by an attending physician, and 50% never or rarely learned from an error made by a fellow resident. CONCLUSIONS: Although resident education about medical errors has improved since 2002, opportunities to model learning from mistakes are frequently missed. KEYWORDS: education; medical error; patient safety; pediatric resident; quality improvement ACADEMIC PEDIATRICS 2013;13:59 64 WHAT S NEW In a survey of residency programs, we found improvement in the proportion of programs with formal curriculum about error prevention and in chief resident knowledge about medical error prevention. There were gaps in training for outpatient medical error prevention and in informal training from mistakes in practice. IT HAS BEEN 10 years since the Institute of Medicine released 2 landmark reports that challenged the country to cross the quality chasm and reduce injury from medical error. 1,2 These reports launched research and intervention efforts in health information technology, 3 5 inpatient medicine, 3,5 7 outpatient medicine, 8 10 and medical education to prevent medical errors. 11 However, a recent study proposes that there has been little change in rates of injury due to medical error. 12 Changes in physician training about error prevention have not been well studied. In 2002, we performed a national survey of pediatric chief residents (chief residents) where we found pediatric resident training about error prevention to be highly varied in quality and frequency. 13 These findings are consistent with other studies. 14 Since 2002, there have been need areas in health care quality that residents must learn about and changes in quality improvement education, including the addition of quality improvement projects, 15 electronic health records, 5,16 checklist implementation, 17 and the adoption of Web-based education. 18 Systems-based practice is one of the Accreditation Council for Graduate Medical Education (ACGME) core competencies, which includes understanding how to identify errors and implement systems solutions. 19 Despite the requirement for formalized curricula, little is known about the use of informal learning in educating residents about medical error. A study in 2006 identified informal learning as a primary opportunity for medical error education. 20 In our 2002 study many chief residents described one-on-one talks or daily conversation as the primary source of medical error education. Changes in this type of informal training about medical errors in recent years is unknown. Many of the mandates focus on inpatient improvement, while the majority of pediatric residents enter outpatient practice upon graduation. Approximately 65% of pediatric residents enter private practice upon graduation and 64% of pediatricians practice in office-based settings. 21 Half of ACADEMIC PEDIATRICS Volume 13, Number 1 Copyright ª 2013 by Academic Pediatric Association 59 January February 2013

60 BRADLEY ET AL ACADEMIC PEDIATRICS paid malpractice claims occur in outpatient care. Outpatient pediatric medical errors are most often medication related. 10,22 Pediatricians are prescribing more medications to children than ever before as rates of medication use have risen in all major categories. 23 In the outpatient setting, physicians still have the responsibility for detecting and reporting adverse events, and doctors are often unaware of errors occurring in the home. 22,24 Our objectives were to describe the amount and type of training that pediatric residents have about medical errors currently and to assess the change in that training since 2002. We hypothesized that with increasing attention to medical error, resident formal training about medical error would have increased, including increases in informal training and education about errors in the outpatient setting. METHODS We performed a telephone survey of a national sample of pediatric chief residents between August and November 2010. To assess the change in pediatric resident education about medical errors over time, we compared our results to the results of the national telephone survey we conducted in 2002. This study was approved by the University of Massachusetts Medical School s institutional review board. PARTICIPANTS We randomly selected 50 programs from the ACGME s list of 198 pediatric residency training programs, excluding the one with which the authors are affiliated. We chose to question chief residents because they are involved in the daily education of residents in their program. When a program was reached, the chief residents who answered the phone was administered the survey. If no contact was made after 3 calls, the program was excluded from the study and another program was randomly selected to replace it. Upon reaching the chief residents, the surveyor (CB) introduced herself and described the study. Interested chief residents were read a verbal consent form before initiating the telephone survey. SURVEY DEVELOPMENT The 31-item survey included 4 domains: demographics, current patient safety curriculum, patient safety knowledge, and informal training from errors in practice. Chief residents were asked to respond to questions considering their program s curriculum and the general experiences of their residents, except for the questions regarding knowledge and learning from errors, where they were asked to respond on the basis of their own knowledge and attitudes. The survey was developed from the prior 2002 survey, with the inclusion of the 21 original survey items and the addition of 10 items about the occurrence and utility of electronic learning and resident quality improvement projects which were not relevant in 2002. The 2010 survey also included items about the frequency that the chief residents learned from the mistakes of attending physicians and peers, an issue not addressed in 2002. In the survey domain current patient safety curriculum, to identify settings used to teach about medical error, we provided a list to which chief residents responded, for each item on the list, yes, no, or I don t know. The list included morbidity and mortality conference, morning report, quality improvement project or research, lecture, informal teaching, intern orientation, pharmacist or nurse reviewing of orders, electronic modules, and individualized feedback. Chief residents were also asked if there were any other settings where they learned about medical error. This list was developed on the basis of the 2002 survey and refined upon pilot testing. Formalized curriculum included all scheduled educational opportunities to teach about medical error, such as morbidity and mortality conferences, lecture, and morning report. Informal learning is defined as unscheduled discussion of medical error in the context of daily clinical interactions. Chief residents were asked an open-ended question about the types of quality improvement projects being done at their institution. Chief resident reports about the types of projects were grouped by one author (CB). Chief residents were also asked if any of the projects were related to medical errors; possible answers were yes or no. In the survey domain patient safety knowledge, the survey included 3 multiple-choice questions related to knowledge about medical errors: the definition of a medical error, the approximate number of pediatric admissions injured by medical error, and the best way to respond to a medical error. After answering the first question about the definition of a medical error, the respondent was told, For the purposes of our discussion, we will define a medical error as a failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim, and examples were given. This question was the first item on the survey, so that the respondent was clear regarding what a medical error is in answering the survey. In the survey domain informal learning from errors in practice, 5 Likert scale questions asked how often the chief residents discussed errors in inpatient and outpatient settings and how often chief residents learned from the errors made by themselves, by fellow residents, or by attending physicians; the response options were never, rarely, often, or always. A complete copy of the survey is available upon request. We pilot tested the survey with 4 chief residents. The final survey took approximately 12 minutes to complete. To assess the concordance of responses between different chief residents at the same site and between the chief resident and the program director at the same site, we administered the survey to the chief residents and the program directors at 3 programs which were not randomized into our study. The chief residents agreed with each other in 94% of responses. The program director agreed with the chief resident in 92% of responses.

ACADEMIC PEDIATRICS MEDICAL ERROR EDUCATION 61 SAMPLE SIZE CALCULATIONS In 2002, 50% of programs reported having a formalized curriculum to teach about medical errors. A sample of 50 programs in the 2010 survey provided 83% power to detect an increase to 75% programs or decline to 25% programs with a formalized curriculum and 95% power to detect an increase to 80% programs or decline to 20% programs with formalized curriculum. ANALYSIS We calculated the percent of total responses to each question. To compare the entire group from the 2002 and 2010 surveys, where the same question was used in both surveys, Chi square analyses were used for categorical data and t-tests for continuous data. If any category in Chi square analyses had less than 5 subjects, Fischer s exact test was used. Statistical significance was set at P ¼.05. RESULTS We phoned 55 chief residents, contacted 51 chief residents, 1 declined to participate, and 50 chose to participate (90% participation rate). Sixty-four percent of chief residents were female; 48% were female in 2002 (P ¼.16). Sixty-six percent of the chief residents worked at a children s hospital; 34% worked at a children s hospital in 2002 (P ¼.12). Of the 50 programs in 2010, 17 were surveyed in 2002 as well. CURRENT PATIENT SAFETY CURRICULUM Ninety-four percent of chief residents stated that their program has a formalized curriculum to discuss medical errors whereas, in 2002, only 50% reported the same (P <.001) (Table 1). Only one program that did not have a formalized curriculum in 2002 still did not have a formalized curriculum in 2010. In the 2010 survey, chief residents reported that the settings used for formalized teaching about medical errors included morbidity and mortality conferences (n ¼ 50), morning reports (n ¼ 50), quality improvement project or research requirement (n ¼ 47), lecture (n ¼ 50), and intern orientation (n ¼ 35). Since 2002, there was a significant increase in the percent of chief residents who report that residents are welcome to participate in morbidity and mortality conference, from 82% in 2002 to 100% in 2010 (P ¼.002). All chief residents state that their residents receive lectures on medical error prevention, an increase from 67% (P <.001) in 2002. Fifty percent of chief residents reported that their program used electronic modules to teach residents about medical errors. However, 31% of those chief residents did not think that these electronic modules were useful. On average, chief residents reported that 85% of pediatric residents in their programs are completing their quality improvement projects. Personally, 78% of chief residents had worked on a quality improvement project. When asked about what the focus of the quality improvement project are, chief residents report that projects focused on Table 1. Comparison of Chief Resident Responses About Training in Medical Errors, 2002 Versus 2010 Response 2002, n (%)* 2010, n (%) (n ¼ 44) (n ¼ 50) Formalized curriculum to <.0001 discuss medical error No 22 (50%) 3 (6%) Yes 22 (50%) 47 (94%) Don t know 0 (0%) 0 (0%) Settings used to teach about medical error Morbidity and mortality 36 (82%) 50 (100%).002 conference Morning report 39 (89%) 50 (100%).02 Quality improvement NA 47 (94%). research Lecture 29 (67%) 50 (100%) <.0001 Intern orientation 36 (82%) 35 (70%).18 Informal teaching 44 (100%) 50 (100%) 1 Pharmacist/nurse 43 (96%) 50 (100%).46 reviewing orders Individualized feedback 44 (100%) 50 (100%) 1 from superiors None 3 (7%) 0 (0%).09 Appropriate response to a medical error Discussion with individuals 10 (23%) 0 (0%) <.0001 involved Team discussion 14 (32%) 2 (10%) Systemic changes 19 (43%) 48 (96%) Case-by-case approach 1 (2%) 0 (0%) *In 2002, 7 chief residents did not answer this question. improving literature about vaccinations available to parents, family-centered rounds, exploring the benefits of evidence-based medicine, learning about free care options for new mothers, and discovering methods of talking to teens about weight management. When asked if any have focused on medical error, it is worth noting that none were related to medical error prevention. Seventy-four percent of those chief residents who did a quality improvement project felt that they learned from the project. Unfortunately, 26% reported, in their own words, that the projects were ineffective, poorly organized, or not monitored in a way that motivated a learning experience. There has been less improvement in the discussion of outpatient error. In 2002, over half (55%) of chief residents stated never discussing medical error in an outpatient care setting (Table 2). In 2010, 10% of chief residents reported never discussing outpatient error, but 82% of chief residents reported rarely discussing medical error in an outpatient care setting. Of 2010 chief residents, only 2% often discussed errors occurring in the outpatient setting, compared to 72% who reported often discussing errors occurring in the inpatient setting. PATIENT SAFETY KNOWLEDGE Compared to the chief residents surveyed in 2002, the 2010 chief residents demonstrated a greater knowledge about what constitutes a medical error and error prevention. Ninety-six percent of 2010 chief residents stated that a systemic change was the best response to a medical P

62 BRADLEY ET AL ACADEMIC PEDIATRICS Table 2. Comparison of Chief Resident Reported Frequency of Discussing Error in the Outpatient Setting, 2002 Versus 2010 Frequency 2002, n (%)* 2010, n (%) (n ¼ 44) (n ¼ 50) Never 24 (55%) 5 (10%) <.0001 Rarely 2 (5%) 41 (82%) Often 15 (34%) 1 (2%) Always 0 (0%) 3 (6%) Don t know 3 (6%) 0 (0%) *In 2002, 7 chief residents did not answer this question. error, whereas only 43% stated the same answer in 2002 (P <.0001). Chief resident respondents to the 2010 survey also more often correctly identified the average number of pediatric admissions injured by medication errors (27% in 2002 vs 72% in 2010; P <.001). INFORMAL TRAINING FROM ERRORS IN PRACTICE All chief residents commented on informal learning, described by the chief residents as unscheduled discussion in daily clinical interactions, such as clinical rounds or pharmacy review of orders, as a method to learn about medical error prevention. Despite 96% reporting formal curricula, 33 chief residents (66%) stated that informal teaching was the primary method used to teach about error, and 100% of those chief residents asserted that this was an effective teaching method. Overall, 96% of chief residents reported that their primary teaching method was effective, whether the method was informal or formal teaching. At the same time, 66% of chief residents stated that he or she would make a change to the current curriculum to teach about medical errors at his or her program. Chief residents mostly commonly reported a more formalized curriculum (78%) as the desired change. When asked about specific opportunities to learn from personal errors or the errors of others, chief residents reported a lack of learning from mistakes made by superiors or peers (Table 3). Ninety-eight percent of surveyed chief residents reported that they have made a medical error during their training compared to 93% (P ¼ 0.3) in 2002. Ninety-six percent reported always or often learning from a medical error he or she had made during their residency. However, 74% of chief residents stated never or rarely learning from a medical error made by an attending physician and 50% reported never or rarely learning from a medical error made by a fellow resident during his or her residency. DISCUSSION In this national survey of pediatric chief residents, we found significant improvements in the frequency of resident education about medical error but noted less improvement in training about outpatient errors or informal learning from mistakes made by peers and attending physicians in clinical practice. As one might expect given recent increased requirements for systems-based learning among P Table 3. Chief Resident Reports of How Often They Learned From Mistakes Made by Others in Their Residency Training Question and Response n (%) How often did you learn from a mistake made by your (N ¼ 50) attending physicians? Never 2 (4%) Rarely 35 (70%) Often 13 (26%) Always 0 (0%) How often did you learn from a mistake made a fellow resident? Never 25 (50%) Rarely 0 (0%) Often 23 (46%) Always 2 (4%) How often did you learn from a mistake made by you? Never 0 (0%) Rarely 4 (8%) Often 22 (44%) Always 24 (48%) residents, we found more extensive training about medical error. Despite this improved formal knowledge, however, chief residents report rarely learning informally from mistakes made by peers and attending physicians. Chief residents also report rarely discussing error in the outpatient setting. We found that chief residents in the later survey were more knowledgeable about medical error than in the earlier survey. Chief residents knew the formal definition of a medical error and reported that they know how to respond to an error in their practice. Chief residents understood that systems improvements were necessary to prevent medical errors. The errors that residents are making today are often associated with teamwork failures, handoff issues, and lack of technical competence. 25 We are not aware of any other studies that evaluate the change in training about medical errors over time. Regarding quality improvement projects, none of the projects discussed in this survey related to medical error. We are aware of no published data about the percentage of quality improvement projects that relate to medical error prevention. Most studies of resident quality improvement projects describe single projects which result in improvements in resident knowledge and self-efficacy about quality improvement. 15,26,27 Programs may encourage quality improvement projects dealing with medical error prevention as a way to combine error prevention and quality improvement curricula more effectively. Despite the frequent use of informal teaching, chief residents reported never or rarely learning from the mistakes of their attending physicians and peers. Several studies indicate that open discussion of medical error may not be modeled in residency training programs. 20,28 Residents report a desire for discussion of real errors committed by senior physicians. Fear of being ostracized or deemed incompetent also causes residents to not discuss their errors. 20 This begins early in training as medical students often observe senior physicians attempting to hide an

ACADEMIC PEDIATRICS MEDICAL ERROR EDUCATION 63 error. 29 In contrast, medical students who see a physician openly take responsibility for an error aspire to those standards. Even in morbidity and mortality conference, a formalized teaching opportunity designed to address patient safety, one study found that errors are often not explicitly mentioned. 30 A desire for a change to his or her institution s approach to medical error is consistent with the findings of our study. This suggests that discussion of personal error, starting with senior physicians as part of formal or informal curricula, could be modeled and accepted by residents if the opportunity existed. This is an important missed opportunity for attending physicians to teach by example. In the area of outpatient medicine, where most children receive their care, chief residents report rarely learning from their mistakes, and little improvement has occurred since 2002. This may reflect the fact that the majority of medical education is in the inpatient setting or that patient safety efforts focus on the inpatient arena. 31 Although less is known about error in the outpatient setting, there is increasing evidence that medication errors are common, 32 and that the use of liquid medication, 33,34 parent measurement of medicines, 35 and low health literacy 36 may contribute to outpatient errors. Training in outpatient medical error prevention could focus on these areas. Although this is a national survey with randomized participation and a high response rate, any study design has limitations. As in any survey, we cannot guarantee that responses accurately represent the curriculum and attitudes at each institution. Chief residents may not have been aware of all aspects of the curriculum or may have reported more socially desirable answers. These biases should be similar between the 2002 and 2010 surveys. In order to assess whether chief residents were aware of all aspects of the curriculum, we did survey chief residents at 3 residency programs and their resident directors and found responses highly consistent between correspondents at the same institution. We used a nonthreatening undergraduate reviewer to potentially reduce social desirability bias. Second, it is impossible to guarantee that chief residents interpreted the questions in the way we intended. We did pilot the survey to improve clarity of questions and face validity. Also, as chief residents are intended to be model residents, their knowledge of the definition and appropriate response to a medical error may be better than the average resident. Finally, the fact that 66% of the chief residents worked at children s hospitals could introduce bias into the study; we are aware of no known association between residencies being at a children s hospital and training characteristics. The survey sampled 50 residency programs, rather than all 198 programs. This sample size, while small, was adequate to detect statistically significant changes when compared to the previous survey. Given the findings of this study, what should pediatric educators do to improve resident education about medical error prevention? Most chief residents report not learning informally from mistakes made by fellow residents and attending physicians. Clinician educators should explicitly discuss medical errors that they make or encounter with trainees in their practice, regardless of the perceived significance of the error or the effect on the patient. Program directors could examine why opportunities for informal training about errors are missed at their institutions. We strongly suggest that attending physicians and residents need to be provided specific instruction about how to use a mistake as a teaching opportunity even when the error does not result in serious injury to the patient. Given the preponderance of outpatient care, improvements are needed in training about response to and prevention of outpatient medical errors in pediatrics. For example, vaccination errors or errors in the home use of medications are common and could be part of pediatric training. 33,34,37,38 CONCLUSIONS In our national survey of pediatric residency programs, we found improvement in the proportion of programs with formal curriculum about error prevention and in chief resident knowledge of the definition of medical errors. There were gaps in training for outpatient medical error prevention. Chief residents reported that they rarely learn informally from mistakes made by their attending physicians and fellow residents. ACKNOWLEDGMENTS We thank Drs Bob Vinci, Adam Pallant, and Jerry Durbin for their help in gathering pilot data. REFERENCES 1. Institute of Medicine. To Err is Human: Building a Safer Health System. Washington, DC: National Acadamies Press; 2000. 2. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001. 3. Bates DW, Cullen DJ, Laird N, et al. Incidence of adverse drug events and potential adverse drug events: Implications for prevention. JAMA. 1995;274:29 34. 4. Walsh K, Adams W, Bauchner H, et al. Medication errors related to computerized order entry for children. Pediatrics. 2006;118: 1872 1879. 5. Walsh KE, Landrigan CP, Adams WG, et al. Effect of computer order entry on prevention of serious medication errors in hospitalized children. Pediatrics. 2008;121:e421 e427. 6. Kaushal R, Bates DW, Landrigan C, et al. Medication errors and adverse drug events in pediatric inpatients. JAMA. 2001;285: 2114 2120. 7. Gandhi TK, Bartel SB, Shulman LN, et al. Medication safety in the ambulatory chemotherapy setting. Cancer. 2005;104:2477 2483. 8. Gandhi TK, Weingart SN, Borus J, et al. Adverse drug events in ambulatory care. N Engl J Med. 2003;348:1556 1564. 9. Kaushal R, Goldmann DA, Keohane CA, et al. Adverse drug events in pediatric outpatients. Ambul Pediatr. 2007;7:383 389. 10. Walsh KE, Mazor K, Stille CJ, et al. Medication errors in the homes of children with chronic conditions. Arch Dis Child. 2011;96:581 586. 11. Wu AW. Medical error: the second victim. BMJ. 2000;320:726. 12. Landrigan CP, Gareth PJ, Bones CB, et al. Temporal trends in rates of patient harm resulting from medical error. N Engl J Med. 2010;363: 2124 2134. 13. Walsh KE, Miller MR, Vinci RJ, et al. Pediatric resident education about medical errors. Ambul Pediatr. 2004;4:514 517.

64 BRADLEY ET AL ACADEMIC PEDIATRICS 14. Huffman-Dracht H, McDonnell WM, Guenther E. Resident education in medical errors. Open Emerg Med J. 2010;3:36 43. 15. Patow CA, Karpovich K, Riesenberg LA, et al. Residents engagement in quality improvement: a systematic review of the literature. Acad Med. 2009;84:1751 1764. 16. Kaushal R, Barker KN, Bates DW. How can information technology improve patient safety and reduce medication errors in children s health care? Arch Pediatr Adolesc Med. 2001;155:1002 1007. 17. Winters BD, Gurses AP, Lehmann H, et al. Clinical review: checklists translating evidence into practice. Crit Care. 2009;13:210. 18. Frush K, Hohenhaus S, Luo X, et al. Evaluation of a Web-based education program on reducing medication dosing error: a multicenter, randomized controlled trial. Pediatr Emerg Care. 2006;22: 62 70. 19. Accreditation Council for Graduate Medical Education. ACGME Program Requirements for Graduate Medical Education in Pediatrics. Accreditation Council for Graduate Medical Education. Available at: http://pediatrics.evms.edu/residency/resgoals/currentacgmeguidelines. pdf. Accessed November 8, 2012. 20. Fischer MA, Mazor KM, Baril J, et al. Learning from mistakes. Factors that influence how students and residents learn from medical errors. J Gen Intern Med. 2006;21:419 423. 21. Bergman AB, DeAngelis CD, Feigin RD, et al. Regulation of working hours for pediatric residents. J Pediatr. 1990;116:478 483. 22. Mohr JJ, Lannon CM, Thoma KA, et al. Learning from errors in ambulatory pediatrics research findings. In: Henriksen K, Battles JB, Marks ES, Lewin DI, eds. Advances in Patient Safety: From Research to Implementation. Research Findings. Vol. 1. Rockville, Md: Agency for Healthcare Research and Quality; 2005. 23. Vernacchio L, Kelly JP, Kaufman DW, et al. Medication use among children <12 years of age in the United States: results from the Slone Survey. Pediatrics. 2009;124:446 454. 24. Walsh KE, Gurwitz JH. Abbreviations in medicine: writing little and communicating less. Arch Dis Child. 2008;93:816 817. 25. Singh H, Thomas EJ, Petersen LA, et al. Medical errors involving trainees: a study of closed malpractice claims from 5 insurers. Arch Intern Med. 2007;167:2030 2036. 26. Djuricich AM, Ciccarelli M, Swigonski NL. A continuous quality improvement curriculum for residents: addressing core competency, improving systems. Acad Med. 2004;79:S65 S67. 27. Mohr JJ, Randolph GD, Laughon MM, et al. Integrating improvement competencies into residency education: a pilot project from a pediatric continuity clinic. Ambul Pediatr. 2003;3:131 136. 28. Wu AW, Folkman S, McPhee SJ, et al. Do house officers learn from their mistakes? JAMA. 1991;265:2089 2094. 29. Martinez W, Lo B. Medical students experiences with medical errors: an analysis of medical student essays. Med Educ. 2008;42: 733 741. 30. Pierluissi E, Fischer MA, Campbell AR, et al. Discussion of medical errors in morbidity and mortality conferences. JAMA. 2003;290: 2838 2842. 31. Neuspiel DR, Guzman M, Harewood C. Improving Error Reporting in Ambulatory Pediatrics With a Team Approach. In: Henriksen K, Battles JB, Keyes MA, Grady ML, eds. Advances in Patient Safety: New Directions and Alternative Approaches. Vol. 1: Assessment. Rockville, MD: Agency for Healthcare Research and Quality; 2008. 32. Walsh KE, Kaushal R, Chessare JB. How to avoid pediatric medication errors: a user s guide to the literature. Arch Dis Child. 2005;90: 698 702. 33. McMahon SR, Rimsza ME, Bay RC. Parents can dose liquid medication accurately. Pediatrics. 1997;100(3 pt 1):330 333. 34. Li S, Lathcer B, Crain E. Acetaminophen and ibuprofen dosing by parents. Pediatr Emerg Care. 2000;16:394 397. 35. Yin HS, Mendesohn A, Wolf MS, et al. Parents medication errors: role of dosing instruments and health literacy. Arch Pediatr Adolesc Med. 2010;164:181 186. 36. Yin HS, Dreyer BP, Foltin G, et al. Association of low caregiver health literacy with reported use of nonstandardized dosing instruments and lack of knowledge of weight-based dosing. Ambul Pediatr. 2007;7: 292 298. 37. Bundy DG, Shore AD, Morlock LL, et al. Pediatric vaccination errors: application of the 5 Rights framework to a national error reporting database. Vaccine. 2009;27:3890 3896. 38. Walsh KE, Stille CJ, Mazor KM, et al. Using Home Visits to Understand Medication Errors in Children. Vol. 4, Technology and Medication Safety. Agency for Healthcare Research and Quality; 2008.