title: Sins of omission: getting too little medical care may be the greatest threat to patient safety.
abstract: BACKGROUND
  Little is known about the relative incidence of serious errors of omission versus errors of commission.
  
  
  OBJECTIVE
  To identify the most common substantive medical errors identified by medical record review.
  
  
  METHODS
  Retrospective cohort study.
  
  
  METHODS
  Twelve Veterans Affairs health care systems in 2 regions.
  
  
  METHODS
  Stratified random sample of 621 patients receiving care over a 2-year period.
  
  
  METHODS
  Classification of reported quality problems.
  
  
  METHODS
  Trained physicians reviewed the full inpatient and outpatient record and described quality problems, which were then classified as errors of omission versus commission.
  
  
  RESULTS
  Eighty-two percent of patients had at least 1 error reported over a 13-month period. The average number of errors reported per case was 4.7 (95% confidence intervals [CI]: 4.4, 5.0). Overall, 95.7% (95% CI: 94.9%, 96.4%) of errors were identified as being problems with underuse. Inadequate care for people with chronic illnesses was particularly common. Among errors of omission, obtaining insufficient information from histories and physicals (25.3%), inadequacies in diagnostic testing (33.9%), and patients not receiving needed medications (20.7%) were all common. Out of the 2,917 errors identified, only 27 were rated as being highly serious, and 26 (96%) of these were errors of omission.
  
  
  CONCLUSIONS
  While preventing iatrogenic injury resulting from medical errors is a critically important part of quality improvement, we found that the overwhelming majority of substantive medical errors identifiable from the medical record were related to people getting too little medical care, especially for those with chronic medical conditions.
authors.affiliation: Veterans Affairs Health Services Research & Development Center of Excellence, Ann Arbor, MI, USA. rhayward@umich.edu
authors.forename: Rodney A
authors.initials: RA
authors.lastname: Hayward
authors.forename: Steven M
authors.initials: SM
authors.lastname: Asch
authors.forename: Mary M
authors.initials: MM
authors.lastname: Hogan
authors.forename: Timothy P
authors.initials: TP
authors.lastname: Hofer
authors.forename: Eve A
authors.initials: EA
authors.lastname: Kerr
mesh_terms: D000208:Acute Disease; D002908:Chronic Disease; D006787:Hospitals, Veterans / Q000592:standards; D006801:Humans; D019300:Medical Errors / Q000145:classification* / Q000706:statistics & numerical data; D011787:Quality of Health Care; D012189:Retrospective Studies; D017751:Safety Management; D014481:United States; D014493:United States Department of Veterans Affairs