The Anatomy of Medical Error: Preventing Harm with People-Based Patient Safety.

Book/Report

The Anatomy of Medical Error: Preventing Harm with People-Based Patient Safety.

October 25, 2006

Geller ES, Johnson D. Virginia Beach, VA: Costal Training Technologies Corporation; 2007. ISBN: 9780966460414.

View more articles from the same authors.

The authors discuss how to increase staff safety awareness by developing four skills: acting, coaching, thinking, and seeing.

Information

Related Resources From the Same Author(s)

Assessment of the AHRQ Patient Safety Initiative: Focus on Implementation and Dissemination Evaluation Report III.

December 17, 2008

Management of drug shortages in the perioperative setting.

February 6, 2013

Assessment of the AHRQ Patient Safety Initiative: Moving from Research to Practice Evaluation Report II (2003–2004).

October 17, 2007

Defusing Disruptive Behavior. A Workbook for Health Care Leaders.

January 7, 2009

Critical Care Safety: Essentials for ICU Patient Care and Technology.

August 8, 2007

How Doctors Think.

March 28, 2007

Improving Hand-Off Communication.

October 31, 2007

Disclosing Medical Errors: A Guide to an Effective Explanation and Apology.

November 22, 2006

Unintended Exposure of Patient Lisa Norris During Radiotherapy Treatment at the Beatson Oncology Centre, Glasgow in January 2006.

November 22, 2006

Failure in Safety-Critical Systems: A Handbook of Accident and Incident Reporting.

March 6, 2005

HSMR: A New Approach for Measuring Hospital Mortality Trends in Canada.

December 12, 2007

Patients as Partners: Toolkit for Implementing National Patient Safety Goal 13.

October 24, 2007

Saving Mothers' Lives: Reviewing Maternal Deaths to Make Motherhood Safer—2003–2005.

January 2, 2008

Safer Care for the Acutely Ill Patient: Learning from Serious Incidents.

October 24, 2007

Case Studies in Patient Safety: Foundations for Core Competencies.

February 18, 2015

Maximize Patient Safety with Advanced Root Cause Analysis.

March 27, 2005

Bridging the gap between work-as-imagined and work-as-done.

July 26, 2017

Talking with Patients and Families about Medical Error: A Guide for Education and Practice.

February 16, 2011

Doctors say patients who lie may put their health at risk.

February 7, 2007

Exploring vulnerability to patient safety events along the age continuum.

April 3, 2019

Preventing Medication Errors: Quality Chasm Series.

July 26, 2006

Assessment of the National Patient Safety Initiative: Context and Baseline Evaluation Report 1.

October 19, 2005

Evaluation of the Patient Safety Improvement Corps: Experiences of the First Two Groups of Trainees.

June 20, 2007

Hospital acquired infections in surgical patients: impact of COVID-19-related infection prevention measures.

April 20, 2022

Surgical fires: decreasing incidence relies on continued prevention efforts.

July 18, 2018

World Patient Safety, Science & Technology Summit.

June 1, 2023 - June 2, 2023

Assessment of the AHRQ Patient Safety Initiative: Final Report Evaluation Report IV.

December 17, 2008

Achieving Strong Teamwork Practices in Hospital Labor and Delivery Units.

December 15, 2010

Assessing Patient Safety Practices and Outcomes in the U.S. Health Care System.

November 4, 2009

Diagnostic Error: Is Overconfidence the Problem.

May 14, 2008

Accountability: Patient Safety and Policy Reform.

March 6, 2005

Medical Harm: Historical, Conceptual, and Ethical Dimensions of Iatrogenic Illness.

March 27, 2005

Beyond Blame: Solutions to America's Other Drug Problem [DVD].

March 27, 2005

Education and training of nurses in the use of advanced medical technologies in home care related to patient safety: a cross-sectional survey.

March 24, 2021

Diagnostic Error in Medicine.

October 7, 2009

Improving Diagnosis in Radiology—Progress and Proposals.

September 13, 2017

Partnering with Patients and Families to Design a Patient- and Family-Centered Health Care System: Recommendations and Promising Practices.

June 4, 2008

Implicit bias and caring for diverse populations: pediatric trainee attitudes and gaps in training.

September 22, 2021

Electronically Generated Medication Administration and Electronic Medication Administration Records for the Prevention of Medication Transcription Errors: Review of Clinical Effectiveness and Safety.

March 8, 2017

Multiple meanings of resilience: health professionals' experiences of a dual element training intervention designed to help them prepare for coping with error.

March 31, 2021

The VA GAPS Center: Stories.

March 6, 2005

Identifying and Understanding Ways to Address the Impact of Racism on Patient Safety in Health Care Settings.

August 31, 2022

Identity Crisis: An Examination of the Costs and Benefits of a Unique Patient Identifier for the US Health Care System.

November 5, 2008

TeamSTEPPS for the COVID-19 Crisis.

February 10, 2021

PEXiS.

March 6, 2005

Patient Safety Huddle.

May 24, 2017

Institute for Patient- and Family- Centered Care.

June 16, 2010

Health Information Technology Leadership Panel: Final Report.

May 25, 2005

The Transforming Care at the Bedside (TCAB) Toolkit.

June 25, 2008

Engaging Physicians in Teamwork Training for Quality and Safety - Or Why Don’t Your Physicians Get Engaged?

June 8, 2022 - June 8, 2022

Addressing the quality and safety gap—parts I-III.

August 12, 2009

Get the Medications Right Institute.

August 7, 2019

TeamSTEPPS Master Training Virtual Course.

September 7, 2023 - November 2, 2023

Deficiencies after the New Electronic Health Record Go-Live at the Mann-Grandstaff VA Medical Center in Spokane, WA.

March 30, 2022

Promoting Patient Safety: An Ethical Basis for Policy Deliberation.

March 6, 2005

The new recommendations on duty hours from the ACGME Task Force.

June 23, 2010

Advances in Patient Safety: From Research to Implementation.

May 11, 2005

Stay Connected: FAQs about Small-Bore Connectors and Tubing Misconnections.

November 6, 2013

Engaging Patients in Improving Ambulatory Care.

April 3, 2013

Procuring Interoperability: Achieving High-Quality, Connected, and Person-Centered Care.

October 24, 2018

Circle Up for COVID-19 Training.

May 13, 2020

The confused and bewildered hospital: adverse event discovery, pay-for-performance, and big data tools as halfway technologies.

July 29, 2020

The Rural VA Multi-Center Medication Reconciliation Quality Improvement Study (R-VA-MARQUIS).

February 12, 2020

Outpatient insulin-related adverse events due to mix-up errors: findings from two national surveillance systems, United States, 2012-2017.

March 24, 2021

Routine multidisciplinary review of severe maternal morbidity is associated with a reduction in preventable cases of severe maternal morbidity.

March 30, 2022

Making safety training stickier: a richer model of safety training engagement and transfer.

September 15, 2021

Testimonial injustice: linguistic bias in the medical records of black patients and women.

June 6, 2021

Association for Professionals in Infection Control and Epidemiology.

July 26, 2006

Interview

In Conversation with Beverley H. Johnson about The Role of Patient's Family In Reducing Harm

June 14, 2023

Safety-I, Safety-II and resilience engineering.

November 6, 2015

Evaluation of Registered Nurse Competency Processes in Veterans Health Administration Facilities.

June 13, 2012

Unexpected Death of a Patient During Treatment With Multiple Medications, Tomah VA Medical Center, Tomah, Wisconsin.

September 16, 2015

Health Information Technology in the United States: The Information Base for Progress.

October 25, 2006

TeamSTEPPS Refresher Course.

October 3, 2023 - October 24, 2023

Interim Report: Review of VHA's Patient Wait Times, Scheduling Practices, and Alleged Patient Deaths at the Phoenix Health Care System.

June 4, 2014

Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System.

September 10, 2014

Deficiencies in Emergent and Outpatient Care of a Patient with Alcohol Use Disorder at the Richard L. Roudebush VA Medical Center in Indianapolis, Indiana.

April 19, 2023

Inadequate Outpatient Mental Health Triage and Care of a Patient at the Chico Community-Based Outpatient Clinic in California.

March 1, 2023

Comprehensive Healthcare Inspection Summary Report: Evaluation of Care Coordination in Veterans Health Administration Facilities, Fiscal Year 2021.

October 12, 2022

The New Electronic Health Record’s Unknown Queue Caused Multiple Events of Patient Harm.

July 27, 2022

Comprehensive Healthcare Inspection Summary Report: Evaluation of Mental Health in Veterans Health Administration Facilities, Fiscal Year 2020.

March 16, 2022

Quality of Care in Cranial Implant Surgeries at James A. Haley VA Medical Center, Tampa, Florida.

April 26, 2006

Quality of Care Concerns and the Facility Response Following a Medical Emergency at the VA Southern Nevada Health Care System in Las Vegas.

July 26, 2023

Multiple Failures in Test Results Follow-up for a Patient Diagnosed with Prostate Cancer at the Hampton VA Medical Center in Virginia.

July 13, 2022

The threat within: mitigating the risk of medical error.

March 25, 2020

WebM&M Cases

The Dropped "No"

October 1, 2011

Placing Diagnosis Errors on the Policy Agenda.

May 21, 2014

Assessment of DoD Wounded Warrior Matters: Managing Risks of Multiple Medications.

March 5, 2014

Assessing frequency and risk of weight entry errors in pediatrics.

February 15, 2017

Ten Years After Keeping Patients Safe: Have Nurses' Work Environments Been Transformed?

April 2, 2014

Healthcare Inspection: Evaluation of the Veterans Health Administration's National Consult Delay Review and Associated Fact Sheet.

January 14, 2015

Critical care simulation education program during the COVID-19 pandemic.

November 10, 2021

It's like sending a message in a bottle: a qualitative study of the consequences of one-way communication technologies in hospitals.

October 13, 2021

Poll: Many Sick Americans Experience Significant Financial Problems and Report Their Care is not Well-Managed.

May 30, 2012

2007 Guide to State Adverse Event Reporting Systems.

March 12, 2008

Reporting incidents involving the use of advanced medical technologies by nurses in home care: a cross-sectional survey and an analysis of registration data.

July 15, 2020

Restoring trust in VA health care.

June 11, 2014

TeamSTEPPS Video Toolkit.

July 21, 2021

Safety in the NICU: preventing medical errors.

March 28, 2007

Making electronic health records both SAFER and SMARTER.

July 27, 2022

Related Resources

Quality of Care Concerns and the Facility Response Following a Medical Emergency at the VA Southern Nevada Health Care System in Las Vegas.

July 26, 2023

Patient Safety Authority Annual Reports.

May 1, 2023

Healthcare Quality and Safety Workforce Report: New Imperatives for Quality and Safety Mean New Imperatives for Workforce Development.

November 9, 2022

Implication of the COVID-19 Pandemic for Patient Safety: A Rapid Review.

August 24, 2022

Under the Skin. The Hidden Toll of Racism on American Lives and on the Health of our Nation.

June 29, 2022

Decontamination of Surgical Instruments.

June 8, 2022

How Discrimination in Health Care Affects Older Americans, and What Health Systems and Providers Can Do.

May 4, 2022

The Joint Commission's new and revised workplace violence prevention standards for hospitals: a major step forward toward improved quality and safety.

May 4, 2022

Nebraska Coalition for Patient Safety Annual Report.

May 1, 2022

The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, and Staff.

April 20, 2022

Parenteral nutrition safety.

September 22, 2021

New Horizons in Patient Safety. Safe Communication: Evidence-based Core Competencies with Case Studies from Nursing.

August 17, 2021

Decision Making in Emergency Medicine: Biases, Errors and Solutions.

June 30, 2021

Transforming Education on Diagnostic Reasoning: Ready, Set, Go!

June 2, 2021

The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity.

May 19, 2021

Sentinel Event Alert 63: optimizing smart infusion pump safety with DERS.

April 21, 2021

Implicit bias in healthcare: clinical practice, research and decision making.

April 21, 2021

Multiple meanings of resilience: health professionals' experiences of a dual element training intervention designed to help them prepare for coping with error.

March 31, 2021

The burden of opioid-related adverse drug events on hospitalized previously opioid-free surgical patients.

March 10, 2021

“I made a mistake!”: a narrative analysis of experienced physicians' stories of preventable error.

January 20, 2021

Bias and racism teaching rounds at an academic medical center.

December 23, 2020

Improving hospital safety culture for falls prevention through interdisciplinary health education.

December 23, 2020

Alternatives to opioid education and a prescription drug monitoring program cumulatively decreased outpatient opioid prescriptions.

December 16, 2020

Deficiencies in the Veterans Crisis Line Response to a Veteran Caller Who Died.

December 16, 2020

Maintaining perioperative safety in uncertain times: COVID-19 pandemic response strategies.

November 18, 2020

COVID-19: an emerging threat to antibiotic stewardship in the emergency department.

October 21, 2020

The Economics of Patient Safety Part III: Long-term Care: Valuing Safety for the Long Haul.

October 7, 2020

Referrals of infection control breaches to public health authorities: ambulatory care settings experience, 2017.

September 23, 2020

Workplace verbal abuse, nurse-reported quality of care, and patient safety outcomes among early-career hospital nurses.

August 19, 2020

Disaster ergonomics: human factors in COVID-19 pandemic emergency management.

August 19, 2020

See More About The Topic

Quality and Safety Professionals

Education and Training

The Anatomy of Medical Error: Preventing Harm with People-Based Patient Safety.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

The Anatomy of Medical Error: Preventing Harm with People-Based Patient Safety.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

PSNet Log in

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