Classics and Emerging Classics

Kotter, a professor at Harvard Business School, outlines the eight stages of a successful change process, as well as common mistakes and pitfalls at each of the stages. These mistakes include not establishing a great enough sense of urgency, not creating a powerful enough guiding coalition, lacking a clear vision, under-communicating the vision by a factor of 10, not removing obstacles to implementation of the vision, not systematically planning for and creating short-term wins, declaring victory too soon, and not anchoring changes in the corporation’s culture. He uses examples of failures from transformation efforts in large and small businesses.

In this article, Rasmussen presents the concept of human error, and how complex and dynamic environments should shift the focus of error. The author argues for a general understanding of human behavior and social interactions in cognitive terms. He presents three cases to analyze human–system interactions, including traditional task analysis and human reliability, causal analysis after an event, and design of reliable work conditions in modern sociotechnical systems. Rasmussen highlights the need for errors to be studied in the context of cognitive control of behavior in complex environments.

This article describes the multifaceted response of Dana-Farber Cancer Institute after a highly publicized medication error in 1995. The authors review a series of interventions designed through the multidisciplinary efforts of nursing, pharmacy, physician, administrative, and other clinical staff. Factors discussed include the role of the patient and family, the need for executive leadership, root cause analyses, a shift to nonpunitive environments, and development of better processes for care. The authors share how a single adverse event catalyzed 7 years of efforts to bring patient safety to the forefront and explain what future steps must occur in the area of patient safety.

The author proposes that, as organizations and their technologies have become more complex and more susceptible to accidents, they must act to increase human complexity to match the system complexity. Using examples from air traffic control and NASA, Weick proposes that organizations should focus on improving communication among individuals and encouraging appropriate delegation of responsibility. The author also promotes praising reliability within the organization. Finally, the author describes the importance of storytelling in organizations, which allows people to better know their system, its potential errors, and how to handle errors in the future.

The authors examine high-reliability organizations, such as aviation and nuclear power, which actively strive to minimize errors and accidents. They describe effective techniques in risk mitigation that can be employed in other large-scale systems like health care. Specifically, the authors stress the need to maintain effective and varied communication within a system. They also discuss how, in order to manage all intended and unintended consequences, decision making in complex systems must be variable, flexible, and shared. Finally, large-scale systems need to maintain strong safety cultures and norms that reinforce common organizational missions and goals.

Gaba analyzes why the health care industry performs as it does and discusses complementary theories of organizational safety in other high-hazard organizations, including aviation, nuclear power plants, and the military. He discusses the two predominant theories of organizational safety, normal accidents theory and high-reliability organization theory, as they apply to the complex world of health care and provides specific parallel examples in other industries. Gaba examines the past record and future potential of health care to set goals in patient safety, provide tools and conditions to achieve those goals, measure attainment of those goals, and take effective action if the goals are not being met.

This commentary discusses the concept of “gaps,” defined as discontinuities in care. The authors expand on the definition by explaining how complicated health systems produce multiple gaps between providers, organizations, and processes. The authors use two cases, which received significant media notoriety, to demonstrate how these gaps are analyzed. As an alternative to the usual focus on systems improvements for patient safety, the authors advocate a better understanding of how individuals handle gaps, particularly when they are created by new systems. Shifting attention to this model for patient safety interventions may offer new research opportunities and mechanisms for improved care.

This article explores the science of how adaptive systems respond to internal and external challenges. Drawing from a literature largely from outside health care, the authors discuss the roles of self-adjusting and interactive systems to manage the interdependence between clinical practice, information management, research, education, and professional development. They describe the role unpredictability plays in these systems, and suggest modified conceptual frameworks for the future. This framework necessitates replacing traditional methods of problem solving with ones that both foster respect for autonomy and respond flexibly to emerging patterns and opportunities. This article is the first in a series of four that explored the topic.

The authors of this article examined patients’ attitudes about physician errors and reported the findings of a survey conducted on randomly selected outpatients. The investigators assessed the attitudes of 149 participants toward three levels of physician mistakes and the impact of physician disclosure. Nearly all patients desired some form of disclosure, and the propensity for litigation did relate to the perceived severity of the error. The authors conclude that open communication between patients and providers is important and may reduce the risk of punitive actions.

This study examined more than 11,000 medication prescribing errors in order to understand the most common types and offer potential prevention strategies. Staff pharmacists detected, recorded, and evaluated each prescribing error and categorized them for further analysis. Findings include a marked increase in the number of errors from 1987 to 1995, including increases in the rate of errors per order per admission. The most common type of error involved dosing. The authors conclude by suggesting a number of strategies, such as the use of information technology and the availability of pharmacists, to counter the perceived growth of medication prescribing errors in the hospital setting.

This study discusses a statistical model to estimate costs associated with drug-related problems in nursing facilities. Using decision analysis techniques and an expert panel of physicians and pharmacists, investigators designed conditional probabilities attributable to drug therapy. Their findings suggest that, for every dollar spent on drug therapy, nearly $1.33 in health care resources are consumed in the treatment of drug-related problems. The authors conclude that improved collaboration among physicians and pharmacists in the nursing home population is likely to reduce the economic impact of drug-related adverse events.

Published in 1954, this article examines the death rate attributable to anesthesia in the surgical services at 10 university hospitals. The researchers retrospectively reviewed 7977 deaths in 599,548 patients from 1948 to 1952 and determined the primary cause of death in each case. The authors state that a patient admitted to a surgical service has a 1 in 75 chance of dying from one cause or another, and a 1 in 95 chance of dying from his or her underlying disease. There was one anesthesia death for every 1,560 patients, a death rate of 0.06%. The researchers state that, in 1952, there were 2.4 times as many deaths from anesthesia as from poliomyelitis, and anesthesia should be viewed as a major public health problem.

This article examines a prospective study of more than 1000 patients admitted to a university medical service. The author studied the type and frequency of hospital complications during a given hospitalization and found that nearly 20% of patients experienced a medical complication. Such patients endured longer hospitalizations while suffering from a variety of complications, including developing acquired infections and reactions to diagnostic procedures, therapeutic drugs, or transfusions. The author thoroughly describes the episodes, which range in severity from minor to fatal. This was one of the first studies to document the frequency of iatrogenic injury in hospital care.

This perspective details the concepts surrounding “accountability” in health care. The discussion begins with explanations of the loci, domains, and procedures of accountability. The authors explore different models of accountability and compare three to illustrate how these fit into the current health care climate. These include professional, economic, and political models, which, the authors argue, fail to serve an appropriate role in health care independent of each other. They propose a stratified model of accountability in which each serves a different purpose in the landscape between patient, provider, managed care, government, and professional association. The authors comment on the challenges with existing models of accountability and provide a detailed understanding of the interplay among them.

The authors provide an introduction to systems failure and human error. They discuss these issues in light of how they affect large complex systems. Many of the examples are from anesthesiology, but the conclusions can be applied broadly throughout health care.

This study of anesthesiology residents demonstrated that fatigue negatively impairs psychomotor functioning and mood but not measures of clinical performance. Investigators examined, scored, and analyzed the observed behaviors of 12 residents in differing states of prior sleep. The findings support the notion that fatigue can lead to errors as a result of impaired cognitive abilities even if the more difficult to measure clinical performance outcomes were less affected. These findings are the first from a comprehensive simulation study addressing the effects of provider fatigue.

This AHRQ-funded study demonstrated that the risk of error increased in association with extended work shifts, overtime, or longer than 40-hour work weeks. Using logbooks from nearly 400 nurses sampled out of a larger group from the American Nurses Association, investigators determined that an alarmingly high percentage of nurses report working extended hours. For those shifts longer than 12.5 hours, the error rate increased notably. The authors advocate for continued attention to relationships between nursing work hours and patient safety, building on past research that linked staffing to poor patient outcomes.

Gender inequities are well-documented in the assessment and treatment of pain. This review summarizes studies on gender differences in experiences and treatment of pain, and assessment of why these differences exist. Findings show there are many reasons for the underappreciation and undertreatment of women’s pain, including cultural expectations for how pain “should” look and attributing women’s pain to emotional or psychological causes.