A Tale of Two Stories: Contrasting Views of Patient Safety.
Cook RI, Woods DD, Miller C. Chicago, IL: National Patient Safety Foundation; 1998.
A report from a workshop, this document is a well-written look at the differences between "first stories" and "second stories" describing major errors. First stories are the easy one-person or one-cause accounts and reactions to
. "So-and-so forgot to check the patient's allergy history." Or "How could they have ignored the alarm and so many other red flags?" Even now, with some penetration of the concepts of
, it is still easy to fall back on the familiar and easy explanation of human error, missing key opportunities to fix underlying problems with processes of care or the way care is organized. Identifying such problems, however, requires the far richer "second stories" about such critical incidents, and these stories do not emerge without hard work. The authors have done this hard work for many publicized medical errors, drawing on follow-up newspaper articles and other investigative documents, often in far more obscure places than headlining first stories. Even readers familiar with
root cause analysis
will likely find value in many of the case studies. And, for those not familiar with such accident investigation techniques, the report provides a very readable introduction to their importance and a resource for further references.
Free full text (PDF)
Swidey N. Boston Globe. January 4, 2004.
National Agenda for Action: Patients and Families in Patient Safety.
Chicago, IL: National Patient Safety Foundation; 2003.
Toward a High Performance Health System: Public-Private Efforts to Make Health Care Safer and More Effective.
Washington, DC: Alliance for Health Reform, The Commonwealth Fund; 2005.
King S. Pediatr Radiol. 2006;36:284-286.
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