Iatrogenic events resulting in intensive care admission: frequency, cause, and disclosure to patients and institutions.

Lisa Soleymani Lehmann; Ann Louise Puopolo; Shimon Shaykevich; Troyen A. Brennan

Study

Iatrogenic events resulting in intensive care admission: frequency, cause, and disclosure to patients and institutions.

April 27, 2005

Lehmann LS, Puopolo AL, Shaykevich S, et al. Am J Med. 2005;118(4):409-13.

View more articles from the same authors.

This prospective observational study from four Boston teaching hospitals reports on the characteristics of patients admitted to intensive care units as the result of iatrogenic events.

PubMed citation

Available at

Related Resources From the Same Author(s)

Analysis of surgical errors in closed malpractice claims at 4 liability insurers.

August 16, 2006

The "hidden curriculum" and residents' attitudes about medical error disclosure: comparison of surgical and nonsurgical residents.

October 9, 2013

Missed and delayed diagnoses in the ambulatory setting: a study of closed malpractice claims.

October 11, 2006

Communication factors in the follow-up of abnormal mammograms.

March 6, 2005

Sleep deprivation, elective surgical procedures, and informed consent.

January 12, 2011

Claims, errors, and compensation payments in medical malpractice litigation.

May 17, 2006

Missed and delayed diagnoses in the emergency department: a study of closed malpractice claims from 4 liability insurers.

October 11, 2006

The Institute of Medicine report on medical errors—could it do harm?

March 27, 2005

Preventing medical injury.

March 27, 2005

Liability impact of the hospitalist model of care.

November 5, 2014

Processes for identifying and reviewing adverse events and near misses at an academic medical center.

January 18, 2017

Hidden curricula, ethics, and professionalism: clinical learning environments in becoming and being a physician: a position paper of the American College of Physicians.

February 28, 2018

The role of medical liability reform in federal health care reform.

July 1, 2009

Patient safety and medical malpractice: a case study.

March 6, 2005

No-fault compensation for medical injuries: the prospect for error prevention.

March 6, 2005

Advising patients about patient safety: current initiatives risk shifting responsibility.

September 7, 2005

Pediatric trainees' speaking up about unprofessional behavior and traditional patient safety threats.

September 30, 2020

Cognitive errors and logistical breakdowns contributing to missed and delayed diagnoses of breast and colorectal cancers: a process analysis of closed malpractice claims.

June 13, 2012

Fostering rational regulation of patient safety.

July 20, 2005

Medical monitoring for pharmaceutical injuries: tort law for the public's health?

March 6, 2005

A middle ground on public accountability.

March 6, 2005

The incorporation of patient safety into board certification examinations.

April 12, 2006

Accidental deaths, saved lives, and improved quality.

October 5, 2005

Adverse drug events in pediatric outpatients.

October 3, 2007

Relation between malpractice claims and adverse events due to negligence. Results of the Harvard Medical Practice Study III.

March 27, 2005

Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I.

March 27, 2005

"Health courts" and accountability for patient safety.

September 13, 2006

Beyond negligence: avoidability and medical injury compensation.

October 31, 2007

Claiming behaviour in a no-fault system of medical injury: a descriptive analysis of claimants and non-claimants.

September 6, 2006

Primary care closed claims experience of Massachusetts malpractice insurers.

October 16, 2013

Risk factors for retained instruments and sponges after surgery.

March 6, 2005

Disclosure of medical injury to patients: an improbable risk management strategy.

January 24, 2007

'Speaking up' about patient safety concerns and unprofessional behaviour among residents: validation of two scales.

August 26, 2015

Ambulatory care adverse events and preventable adverse events leading to a hospital admission.

April 18, 2007

Speaking up about traditional and professionalism-related patient safety threats: a national survey of interns and residents.

May 10, 2017

Who pays for medical errors? An analysis of adverse event costs, the medical liability system, and incentives for patient safety improvement.

February 6, 2008

The role of physician specialty board certification status in the quality movement.

March 6, 2005

Role-modeling and medical error disclosure: a national survey of trainees.

February 12, 2014

Process of care failures in breast cancer diagnosis.

May 13, 2009

Economic value of pharmacist-led medication reconciliation for reducing medication errors after hospital discharge.

November 2, 2016

Automatable algorithms to identify nonmedical opioid use using electronic data: a systematic review.

November 8, 2017

Engaging patients in the use of real-time electronic clinical data to improve the safety and reliability of their own care.

May 4, 2022

Risk factors for patient-reported errors during cancer follow-up: results from a national survey in Denmark.

September 27, 2017

How communication among members of the health care team affects maternal morbidity and mortality.

January 18, 2017

Evaluation of a patient-centered fall-prevention tool kit to reduce falls and injuries: a nonrandomized controlled trial.

December 2, 2020

Defensive medicine among high-risk specialist physicians in a volatile malpractice environment.

June 8, 2005

Doing right by our patients when things go wrong in the ambulatory setting.

February 12, 2014

Screening for adverse drug events: a randomized trial of automated calls coupled with phone-based pharmacist counseling.

March 6, 2019

An insurer's care transition program emphasizes medication reconciliation, reduces readmissions and costs.

July 27, 2016

Predictors of response rates of safety culture questionnaires in healthcare: a systematic review and analysis.

October 26, 2022

What has an Airbus A380 captain got to do with OMFS? Lessons from aviation to improve patient safety.

June 12, 2019

Evaluation of a nurse-led safety program in a critical care unit.

April 10, 2013

Improving patients' intensive care admission through multidisciplinary simulation-based crisis resource management: a qualitative study.

September 20, 2023

Patient safety, quality care, and service utilization with PLATO (Physician Leadership for Accurate and Timely Orders): a pilot study.

August 26, 2009

Incidence and types of preventable adverse events in elderly patients: population based review of medical records.

March 27, 2005

Correlation between hospital finances and quality and safety of patient care.

September 4, 2019

Dimensions of safety culture: a systematic review of quantitative, qualitative and mixed methods for assessing safety culture in hospitals.

September 1, 2021

Human factors—recognising and minimising errors in our day to day practice.

February 10, 2016

Adverse events in women giving birth in a labor ward: a retrospective record review study.

November 3, 2021

'Broken hospital windows': debating the theory of spreading disorder and its application to healthcare organizations.

May 9, 2018

Pediatric aspects of inpatient health information technology systems.

February 4, 2009

Talking with patients about other clinicians' errors.

November 6, 2013

Operating room teamwork among physicians and nurses: teamwork in the eye of the beholder.

May 17, 2006

Routine failures in the process for blood testing and the communication of results to patients in primary care in the UK: a qualitative exploration of patient and provider perspectives.

September 9, 2015

Test result communication in primary care: a survey of current practice.

August 19, 2015

Improving the accuracy of patient identification in the medication-use process.

February 8, 2006

Every error a treasure: improving medication use with a nonpunitive reporting system.

July 18, 2007

Good people who try their best can have problems: recognition of human factors and how to minimise error.

January 27, 2016

International recommendations for national patient safety incident reporting systems: an expert Delphi consensus-building process.

February 1, 2017

Prospective evaluation of a multifaceted intervention to improve outcomes in intensive care: the Promoting Respect and Ongoing Safety through Patient Engagement Communication and Technology study.

May 24, 2017

Preventable adverse drug events among inpatients: a systematic review.

August 29, 2018

Safety hazards in cancer care: findings using three different methods.

July 27, 2011

Decreasing errors in pediatric continuous intravenous infusions.

May 24, 2006

Challenging hierarchy in healthcare teams--ways to flatten gradients to improve teamwork and patient care.

April 19, 2017

Leading article: how can I optimise my role as a leader within the surgical team?

August 31, 2016

Applying decision science to the prioritization of healthcare-associated infection initiatives.

October 27, 2021

Are you surgically current? Lessons from aviation for returning to non-urgent surgery following COVID-19.

July 22, 2020

Electronic fetal heart rate monitoring: applying principles of patient safety.

May 16, 2012

Instituting vincristine minibag administration: an innovative strategy using simulation to enhance chemotherapy safety.

December 6, 2017

Applying aviation factors to oral and maxillofacial surgery—the human element.

February 1, 2012

Abbreviation use decreases effective clinical communication and can compromise patient safety.

October 4, 2023

Computer based medication error reporting: insights and implications.

June 21, 2006

Nurses' medication work: what do nurses know?

November 17, 2010

Hospital staffing and health care–associated infections: a systematic review of the literature.

October 3, 2018

'Doing the best we can': Registered nurses' experiences and perceptions of patient safety in intensive care during COVID-19.

September 7, 2022

Healthcare system-wide implementation of opioid-safety guideline recommendations: the case of urine drug screening and opioid-patient suicide- and overdose-related events in the Veterans Health Administration.

April 5, 2017

Helping healthcare teams to debrief effectively: associations of debriefers' actions and participants' reflections during team debriefings.

August 24, 2022

An effort to improve electronic health record medication list accuracy between visits: patients' and physicians' response.

March 19, 2008

User-centered collaborative design and development of an inpatient safety dashboard.

September 20, 2017

The impact of nontechnical skills on technical performance in surgery: a systematic review.

January 30, 2005

Automated electronic reminders to prevent miscommunication among primary medical, surgical and anaesthesia providers: a root cause analysis.

August 22, 2012

Observational teamwork assessment for surgery: feasibility of clinical and nonclinical assessor calibration with short-term training.

May 30, 2012

Situational awareness—what it means for clinicians, its recognition and importance in patient safety.

August 24, 2016

Work system design for patient safety: the SEIPS model.

October 12, 2011

Making soft intelligence hard: a multi-site qualitative study of challenges relating to voice about safety concerns.

March 14, 2018

Explaining Michigan: developing an ex post theory of a quality improvement program.

August 3, 2011

Relationship between complaints and quality of care in New Zealand: a descriptive analysis of complainants and non-complainants following adverse events.

February 15, 2006

Reducing accidental extubation in neonates.

March 5, 2008

The economic consequences of medical injuries: implications for a no-fault insurance plan.

March 6, 2005

Sleep deprivation, physician performance, and patient safety.

November 25, 2009

Related Resources

Patient Safety Innovations

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

May 31, 2023

Identification of patient safety threats in a post-intensive care clinic.

May 31, 2023

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

Using a learning system approach to improve safety for prone-position ventilation patients.

April 26, 2023

July 20, 2022

Adverse event reviews in healthcare: what matters to patients and their family? A qualitative study exploring the perspective of patients and family.

June 1, 2022

Increased mortality and costs associated with adverse events in intensive care unit patients.

April 6, 2022

Patient harm and institutional avoidability of out-of-hours discharge from intensive care: an analysis using mixed methods.

March 23, 2022

Error reduction in trauma care: lessons from an anonymized, national, multicenter mortality reporting system.

March 23, 2022

Proceed with reasonable care: when legal principles inform training to prevent harm during the childbirth.

February 9, 2022

Learning from patient safety incidents involving acutely sick adults in hospital assessment units in England and Wales: a mixed methods analysis for quality improvement.

August 25, 2021

Implementing a watcher program to improve timeliness of recognition of deterioration in hospitalized children.

June 30, 2021

Problems in care and avoidability of death after discharge from intensive care: a multi-centre retrospective case record review study.

February 10, 2021

Making communication and resolution programmes mission critical in healthcare organisations.

November 11, 2020

Reimagining Healing after Healthcare Harm: The Potential for Restorative Practices.

July 29, 2020

Patient preferences in cases of Inter-system Medical Error Discovery (IMED).

September 11, 2019

When there's no one to whom an error can be disclosed, how should an error be handled?

August 14, 2019

New persistent opioid use after postoperative intensive care in US veterans.

June 19, 2019

Reducing medication errors in critical care patients: pharmacist key resources and relationship with medicines optimisation.

May 2, 2018

Burnout in the neonatal intensive care unit and its relation to healthcare-associated infections.

June 14, 2017

Errors, omissions, and outliers in hourly vital signs measurements in intensive care.

October 26, 2016

Patient safety events and harms during medical and surgical hospitalizations for persons with serious mental illness.

June 1, 2016

Relationship between job burnout, psychosocial factors and health care–associated infections in critical care units.

March 30, 2016

Factors associated with post-intensive care unit adverse events: a clinical validation study.

October 29, 2014

Nighttime cross-coverage is associated with decreased intensive care unit mortality. A single-center study.

September 3, 2014

Failure events in transition of care for surgical patients.

March 5, 2014

Eliminating central line-associated bloodstream infections: a national patient safety imperative.

January 15, 2014

Impact of contact isolation for multidrug-resistant organisms on the occurrence of medical errors and adverse events.

October 23, 2013

Improving adverse drug event detection in critically ill patients through screening intensive care unit transfer summaries.

July 31, 2013

A randomized trial of nighttime physician staffing in an intensive care unit.

June 5, 2013

See More About The Topic

Intensive Care Units

Health Care Providers

Facility and Group Administrators

Risk Managers

Quality and Safety Professionals

Iatrogenic events resulting in intensive care admission: frequency, cause, and disclosure to patients and institutions.

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Iatrogenic events resulting in intensive care admission: frequency, cause, and disclosure to patients and institutions.

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site