Commentary Beyond the organisational accident: the need for "error wisdom" on the frontline. Citation Text: Reason J. Beyond the organisational accident: the need for "error wisdom" on the frontline. Qual Saf Health Care. 2004;13 Suppl 2:ii28-33. Copy Citation Format: Google ScholarPubMedBibTeXEndNote X3 XMLEndNote 7 XMLEndnote taggedPubMedIdRIS Download Citation Save Save to your library Print Share Facebook Twitter Linkedin Copy URL March 6, 2005 Reason J. Qual Saf Health Care. 2004;13 Suppl 2:ii28-33. View more articles from the same authors. This commentary uses a case study involving a fatal medication error to illustrate the importance of mental skills that improve recognition of potentially adverse events. PubMed citation Available at Free full text Save Save to your library Print Share Facebook Twitter Linkedin Copy URL Cite Citation Citation Text: Reason J. Beyond the organisational accident: the need for "error wisdom" on the frontline. Qual Saf Health Care. 2004;13 Suppl 2:ii28-33. Copy Citation Format: Google ScholarPubMedBibTeXEndNote X3 XMLEndNote 7 XMLEndnote taggedPubMedIdRIS Download Citation Related Resources From the Same Author(s) Accident analysis of large-scale technological disasters applied to an anaesthetic complication. March 6, 2005 Human factor in cardiac surgery: errors and near misses in a high technology medical domain. March 27, 2005 Human error: models and management. March 27, 2005 Safety paradoxes and safety culture. April 9, 2003 Probabilistic risk assessment of accidental ABO-incompatible thoracic organ transplantation before and after 2003. February 6, 2008 American College of Endocrinology and American Association of Clinical Endocrinologists position statement on patient safety and medical system errors in diabetes and endocrinology. 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Accident analysis of large-scale technological disasters applied to an anaesthetic complication. March 6, 2005
Human factor in cardiac surgery: errors and near misses in a high technology medical domain. March 27, 2005
Probabilistic risk assessment of accidental ABO-incompatible thoracic organ transplantation before and after 2003. February 6, 2008
American College of Endocrinology and American Association of Clinical Endocrinologists position statement on patient safety and medical system errors in diabetes and endocrinology. December 7, 2005
The 5th National Audit Project (NAP5) on accidental awareness during general anaesthesia: patient experiences, human factors, sedation, consent and medicolegal issues. November 12, 2014
5th National Audit Project (NAP5) on accidental awareness during general anaesthesia: protocol, methods, and analysis of data. September 24, 2014
Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices. March 6, 2013
Association of patient and family reports of hospital safety climate with language proficiency in the US. June 29, 2022
Adverse drug events caused by three high-risk drug-drug interactions in patients admitted to intensive care units: a multicentre retrospective observational study. October 18, 2023
A retrospective audit of postoperative days alive and out of hospital, including before and after implementation of the WHO surgical safety checklist. February 2, 2022
Implementation of the I-PASS handoff program in diverse clinical environments: a multicenter prospective effectiveness implementation study. November 16, 2022
Preventable hospital admissions related to medication (HARM): cost analysis of the HARM study. March 1, 2011
Association of diagnostic stewardship for blood cultures in critically ill children with culture rates, antibiotic use, and patient outcomes: results of the Bright STAR Collaborative. May 18, 2022
The effect of computerised decision support alerts tailored to intensive care on the administration of high-risk drug combinations, and their monitoring: a cluster randomised stepped-wedge trial. February 14, 2024
Surgical safety does not happen by accident: learning from perioperative near miss case studies. January 24, 2024
Physician and nurse well-being and preferred interventions to address burnout in hospital practice: factors associated with turnover, outcomes, and patient safety. July 19, 2023
Seroprevalence of SARS-CoV-2 among frontline health care personnel in a multistate hospital network--13 academic medical centers, April-June 2020. September 23, 2020
Burnout in the neonatal intensive care unit and its relation to healthcare-associated infections. June 14, 2017
Electronic medical record alert associated with reduced opioid and benzodiazepine coprescribing in high-risk Veteran patients. January 17, 2018
A prospective, observational study of the effects of implementation strategy on compliance with a surgical safety checklist. October 30, 2013
Surviving Sepsis Campaign: international guidelines for management of sepsis and septic shock: 2016 March 3, 2017
Clinical communities at Johns Hopkins Medicine: an emerging approach to quality improvement. September 2, 2015
Organisational culture: variation across hospitals and connection to patient safety climate. January 5, 2011
Medical error disclosure among pediatricians: choosing carefully what we might say to parents. October 15, 2008
Risk factors for clinically relevant deviations in patients' medication lists reported by patients in personal health records: a prospective cohort study in a hospital setting. March 2, 2022
Handling injectable medications in anaesthesia: Guidelines from the Association of Anaesthetists. August 23, 2023
Diagnostic stewardship to improve patient outcomes and healthcare-associated infection (HAI) metrics. May 22, 2024
The Safe Home Care Intervention Study: implementation methods and effectiveness evaluation. May 8, 2024
Implementation and facilitation of post-resuscitation debriefing: a comparative crossover study of two post-resuscitation debriefing frameworks. November 2, 2022
Rates of surgical consultations after emergency department admission in Black and White Medicare patients. October 26, 2022
Impact of performance and information feedback on medical interns' confidence-accuracy calibration. April 3, 2024
Prospective study of the multisite spread of a medication safety intervention: factors common to hospitals with improved outcomes. February 7, 2024
Electronic prescribing systems in hospitals to improve medication safety: a multi-methods research programme. December 21, 2022
Prevalence and causes of diagnostic errors in hospitalized patients under investigation for COVID-19. April 12, 2023
Inappropriate dosing of direct oral anticoagulants in patients with atrial fibrillation. April 28, 2021
The Diagnostic Error Index: a quality improvement initiative to identify and measure diagnostic errors. February 10, 2021
Enabling a learning healthcare system with automated computer protocols that produce replicable and personalized clinician actions. August 4, 2021
Comparative effectiveness of a serious game and an e-module to support patient safety knowledge and awareness. February 22, 2017
Medication safety in the operating room: literature and expert-based recommendations. February 22, 2017
Physicians' perspectives regarding prescription drug monitoring program use within the Department of Veterans Affairs: a multi-state qualitative study. April 18, 2018
Supporting doctors as healthcare quality and safety advocates: recommendations from the Association of Surgeons in Training (ASiT). July 25, 2018
The 2017 ACGME common work hour standards: promoting physician learning and professional development in a safe, humane environment. January 31, 2018
Medication-related emergency department visits and hospital admissions in pediatric patients: a qualitative systematic review. October 16, 2013
Patient-led training on patient safety: a pilot study to test the feasibility and acceptability of an educational intervention. September 4, 2013
Effects of an enhanced discharge planning intervention for hospitalized older adults: a randomized trial. November 14, 2012
Reviewing deaths in British and US hospitals: a study of two scales for assessing preventability. July 20, 2016
Prevalence of inappropriate antibiotic prescriptions among US ambulatory care visits, 2010–2011. May 25, 2016
Cluster randomized trial to evaluate the impact of team training on surgical outcomes. October 5, 2016
Developing and deploying a patient safety program in a large health care delivery system: you can't fix what you don't know about. October 21, 2015
Undermining and bullying in surgical training: a review and recommendations by the Association of Surgeons in Training. October 14, 2015
Medication reconciliation at admission and discharge: an analysis of prevalence and associated risk factors. September 23, 2015
Medication-related emergency department visits in pediatrics: a prospective observational study. February 25, 2015
Medication safety at the interface: evaluating risks associated with discharge prescriptions from mental health hospitals. January 20, 2016
Beyond 'find and fix': improving quality and safety through resilient healthcare systems. April 15, 2020
Impact of interactions between drugs and laboratory test results on diagnostic test interpretation—a systematic review. November 21, 2018
The relationship between the learning and patient safety climates of clinical departments and residents' patient safety behaviors. October 17, 2018
Discrepant perceptions of communication, teamwork and situation awareness among surgical team members. March 23, 2011
Feasibility of centre-based incident reporting in primary healthcare: the SPIEGEL study. February 23, 2011
A human factors framework and study of the effect of nursing workload on patient safety and employee quality of working life. February 2, 2011
Measuring hospital adverse events: assessing inter-rater reliability and trigger performance of the Global Trigger Tool. June 30, 2010
The role of the medical emergency team in end-of-life care: a multicenter, prospective, observational study. January 4, 2012
Awareness with recall during general anaesthesia: a prospective observational evaluation of 4001 patients. August 20, 2008
Resident uncertainty in clinical decision making and impact on patient care: a qualitative study. April 16, 2008
Improving transfusion safety: implementation of a comprehensive computerized bar code-based tracking system for detecting and preventing errors. April 9, 2008
Deviation from a preoperative surgical and anaesthetic care plan is associated with increased risk of adverse intraoperative events in major abdominal surgery. December 5, 2012
Lessons learnt from incidents reported by postgraduate trainees in Dutch general practice. A prospective cohort study. October 5, 2011
What makes hospitalized patients more vulnerable and increases their risk of experiencing an adverse event? September 21, 2011
The introduction of a surgical safety checklist in a tertiary referral obstetric centre. July 27, 2011
A randomised controlled trial of the effect of continuous electronic physiological monitoring on the adverse event rate in high risk medical and surgical patients. December 6, 2006
A new safety event reporting system improves physician reporting in the surgical intensive care unit. June 14, 2006
Simulation based teamwork training for emergency department staff: does it improve clinical team performance when added to an existing didactic teamwork curriculum? April 5, 2006
Exploring the factors that promote or diminish a psychologically safe environment: a qualitative interview study with critical care staff. September 22, 2021
Support for healthcare professionals after surgical patient safety incidents: a qualitative descriptive study in 5 teaching hospitals. May 26, 2021
Distractions in the cardiac catheterisation laboratory: impact for cardiologists and patient safety. February 24, 2021
Systems approach to health service design, delivery and improvement: a systematic review and meta-analysis. February 3, 2021
It’s time to consider national culture when designing team training initiatives in healthcare. January 27, 2021
Covid-19: Assessing the Risk to Public Protection Posed by a Doctor as a Result of Concerns about their Practice during the Pandemic. September 30, 2020
Impacts of operational failures on primary care physicians' work: a critical interpretive synthesis of the literature. May 13, 2020
Uncovering, creating or constructing problems? Enacting a new role to support staff who raise concerns about quality and safety in the English National Health Service February 19, 2020
The rise of human factors: optimising performance of individuals and teams to improve patients' outcomes. July 10, 2019
A safety evaluation of the impact of maternity-orientated human factors training on safety culture in a tertiary maternity unit. June 19, 2019
Measuring variation in use of the WHO surgical safety checklist in the operating room: a multicenter prospective cross-sectional study. December 17, 2014
Mentorship for newly appointed physicians: a strategy for enhancing patient safety? September 3, 2014
A qualitative evaluation of the barriers and facilitators toward implementation of the WHO surgical safety checklist across hospitals in England: lessons from the "Surgical Checklist Implementation Project." August 20, 2014