Probabilistic risk assessment of accidental ABO-incompatible thoracic organ transplantation before and after 2003.

Richard I. Cook; John Wreathall; Alison Smith; David C. Cronin; Oswaldo Rivero; Robert C. Harland; Jai Raman; James Battles; James Reason

Study

Probabilistic risk assessment of accidental ABO-incompatible thoracic organ transplantation before and after 2003.

February 6, 2008

Cook RI, Wreathall J, Smith A, et al. Transplantation. 2007;84(12):1602-1609.

View more articles from the same authors.

This study discovered that the observed and predicted likelihoods of incompatible organ transplantation are comparable, but two-fold less likely since system changes were adopted after a widely publicized heart-lung transplant error in 2003.

PubMed citation

Free full text

Related Resources From the Same Author(s)

“Those found responsible have been sacked”: some observations on the usefulness of error.

October 10, 2010

The role of automation in complex system failures.

May 11, 2005

A systems approach to analyzing and preventing hospital adverse events.

June 24, 2020

Accidental iatrogenic pneumothorax in hospitalized patients.

March 15, 2006

Assessing patient safety in the United States: challenges and opportunities.

April 3, 2005

Simulation study of rested versus sleep-deprived anesthesiologists.

January 9, 2005

Lessons learned from implementing a principled approach to resolution following patient harm.

January 9, 2019

Patient Safety Innovations

Pharmacist-led mobile health intervention and transplant medication safety: a randomized controlled clinical trial.

April 7, 2022

A Tale of Two Stories: Contrasting Views of Patient Safety.

March 27, 2005

The Critical Care Safety Study: the incidence and nature of adverse events and serious medical errors in intensive care.

August 24, 2005

Adverse events related to accidental unintentional ingestions from cough and cold medications in children.

August 26, 2020

Understanding hazards for adverse drug events among older adults after hospital discharge: insights from frontline care professionals.

July 20, 2022

Simulation-based assessment of the management of critical events by board-certified anesthesiologists.

September 13, 2017

Competition and health plan performance: evidence from health maintenance organization insurance markets.

April 27, 2005

Mortality due to hospital-acquired infection after cardiac surgery.

June 1, 2022

Assessment of overuse of medical tests and treatments at US hospitals using Medicare claims.

May 19, 2021

Operating at the sharp end: the complexity of human error.

March 6, 2005

Mistaking error.

March 27, 2005

Learning from diagnostic errors to improve patient safety when GPs work in or alongside emergency departments: incorporating realist methodology into patient safety incident report analysis.

January 12, 2022

Healing our own: a randomized trial to assess benefits of peer support.

February 2, 2022

Critical incident reports concerning anaesthetic equipment: analysis of the UK National Reporting and Learning System (NRLS) data from 2006-2008.

August 31, 2011

Show me the money, I'll show you my complications: impacts of incentivized incident self-reporting among surgeons.

March 2, 2022

I'm sorry: laws that support apologies in health care.

February 5, 2020

Disparities in adverse event reporting for hospitalized children.

August 3, 2022

How health systems decide to use artificial intelligence for clinical decision support.

April 6, 2022

A comprehensive quality assurance program for personnel and procedures in radiation oncology: value of voluntary error reporting and checklists.

August 7, 2013

Patient safety and quality improvement adaptation during the COVID-19 pandemic.

April 21, 2021

New graduate registered nurses: Risk mitigation strategies to ensure safety and successful transition to practice.

August 3, 2022

Accuracy of practitioner estimates of probability of diagnosis before and after testing.

May 5, 2021

Quantifying nursing workflow in medication administration.

January 9, 2008

Medication errors in anesthesiology: is it time to train by example? Vignettes can assess error awareness, assessment of harm, disclosure, and reporting practices.

October 28, 2020

Adapting to new technologies in the operating room.

March 27, 2005

An intervention to decrease catheter-related bloodstream infections in the ICU.

January 3, 2007

Sleepy nurses: are we willing to accept the challenge today?

June 20, 2007

Effect of a pharmacy-based centralized intravenous admixture service on the prevalence of medication errors: a before-and-after study.

August 10, 2022

Association between hospital acquired harm outcomes and membership in a national patient safety collaborative.

August 10, 2022

Lessons from the war on cancer: the need for basic research on safety.

May 11, 2005

Variation in electronic test results management and its implications for patient safety: a multisite investigation.

August 19, 2020

Key potentially inappropriate drugs in pediatrics: the KIDs list.

June 24, 2020

The influence of the structure and culture of medical group practices on prescription drug errors.

August 31, 2005

Enacting the Washington state patient safety act requiring hospital staffing plans for nursing services and establishing recordkeeping and reporting requirements.

March 6, 2005

The costs associated with adverse drug events among older adults in the ambulatory setting.

December 7, 2005

The effect of the fit between organizational culture and structure on medication errors in medical group practices.

February 7, 2007

The delivery of safe and effective test result communication, management and follow-up.

September 27, 2023

Transforming the medication regimen review process using telemedicine to prevent adverse events.

December 16, 2020

Current pulse: can a production system reduce medical errors in health care?

August 22, 2007

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

Systems approach to health service design, delivery and improvement: a systematic review and meta-analysis.

February 3, 2021

Development and expression of a high-reliability organization.

December 1, 2021

Second victim support programs for healthcare organizations.

July 29, 2020

Medication reconciliation in ambulatory oncology.

December 5, 2007

Race and socioeconomic bias in pediatric cardiac transplantation.

February 8, 2023

Studying the technical work of emergency care.

October 31, 2007

A high-reliability organization mindset.

February 22, 2023

Recommendations for the safe, effective use of adaptive CDS in the US healthcare system: an AMIA position paper.

April 21, 2021

Teamwork before and during COVID-19: the good, the same, and the ugly….

August 24, 2022

Purchase of prescription medicines via social media: a survey-based study of prevalence, risk perceptions, and motivations.

October 27, 2021

The National Emergency Department Safety Study: study rationale and design.

January 9, 2008

Interventions promoting employee "speaking-up" within healthcare workplaces: a systematic narrative review of the international literature.

June 2, 2021

Implementing human factors in anaesthesia: guidance for clinicians, departments and hospitals: Guidelines from the Difficult Airway Society and the Association of Anaesthetists.

March 1, 2023

Assessment of perioperative outcomes among surgeons who operated the night before.

June 8, 2022

The Patient Safety Leadership Academy at the University of Pennsylvania: the first cohort's learning experience.

June 13, 2007

The electronic prescribing of subcutaneous infusions: a before-and-after study assessing the impact upon patient safety and service efficiency.

June 15, 2022

The impact of an electronic alert to reduce the risk of co-prescription of low molecular weight heparins and direct oral anticoagulants.

July 6, 2022

Eliminating explicit and implicit biases in health care: evidence and research needs.

February 23, 2022

Assessing resident and attending error and adverse events in the emergency department.

March 2, 2022

Medication order errors at hospital admission among children with medical complexity

July 8, 2020

Toward constructive change after making a medical error: recovery from situations of error theory as a psychosocial model for clinician recovery.

August 10, 2022

Malpractice cases in breast surgery: an assessment of litigation involving surgeons.

December 1, 2021

Children and the opioid epidemic: age-stratified exposures and harms.

October 21, 2020

Association of interruptions with an increased risk and severity of medication administration errors.

May 5, 2010

Prosocial voice in the hierarchy of healthcare professionals: the role of emotions after harmful patient safety incidents.

March 22, 2023

Implementing root cause analysis and action: integrating human factors to create strong interventions and reduce risk of patient harm.

July 20, 2022

Impact of pharmacist-led multidisciplinary medication review on the safety and medication cost of the elderly people living in a nursing home: a before-after study.

February 12, 2020

Using smart IV infusion pumps outside of patient rooms.

February 2, 2022

Effectiveness of pharmacist intervention to reduce medication errors and health-care resources utilization after transitions of care: a meta-analysis of randomized controlled trials.

July 19, 2017

Targeting zero harm: a stretch goal that risks breaking the spring.

August 12, 2020

Hospital quality-review spending and patient safety: a longitudinal analysis using instrumental variables.

July 7, 2021

Opioid dependence and overdose after surgery: rate, risk factors, and reasons.

September 21, 2022

Body mass index category and adverse events in hospitalized children.

July 27, 2022

There's no place like home--integrating a pharmacist into the hospital-in-home model.

March 17, 2021

System factors affecting patient safety in the OR: an analysis of safety threats and resiliency.

August 25, 2021

Risk from delayed or missed care and non-COVID-19 outcomes for older patients with chronic conditions during the pandemic.

June 8, 2022

Identifying safe care processes when GPs work in or alongside emergency departments: a realist evaluation.

December 15, 2021

Intraoperative sentinel events in the era of surgical safety checklists: results of a national survey.

March 3, 2021

A system analysis of a suboptimal surgical experience.

February 4, 2009

A high-reliability organization framework for health care: a multiyear implementation strategy and associated outcomes.

November 4, 2020

Non-technical skills in surgery during the COVID-19 pandemic: an observational study.

March 9, 2022

How communication "failed" or "saved the day": counterfactual accounts of medical errors.

February 3, 2021

Implementing standardized reporting and safety checklists.

June 1, 2011

Influence of organizational climate and clinician morale on seclusion and physical restraint use in inpatient psychiatric units.

September 1, 2021

Supporting the emotional well-being of health care workers during the COVID-19 pandemic.

August 5, 2020

Black or 'other'? Doctors may be relying on race to make decisions about your health.

May 5, 2021

Resilience and resilience engineering in health care.

July 30, 2014

Secondary traumatic stress in ob-gyn: a mixed methods analysis assessing physician impact and needs.

July 21, 2021

Cracking the code for quality: the interrelationships of culture, nurse demographics, advocacy, and patient outcomes.

March 11, 2020

Prescribing patterns of heart failure-exacerbating medications following a heart failure hospitalization.

February 12, 2020

Combined proactive risk assessment: unifying proactive and reactive risk assessment techniques in health care.

June 29, 2022

Impact of intensive care unit discharge time on patient outcome.

January 17, 2007

Cold debriefings after in-hospital cardiac arrest in an international pediatric resuscitation quality improvement collaborative.

September 2, 2020

Related Resources

Factors associated with diagnostic error: an analysis of closed medical malpractice claims.

April 19, 2023

Crisis scenarios for simulation-based nontechnical skills training for cardiac surgery teams: a national survey among cardiac anesthesiologists, cardiac surgeons, clinical perfusionists, and cardiac operating room nurses.

April 12, 2023

Surgeons and systems working together to drive safety and quality.

March 29, 2023

Association of measured quality and future financial performance among hospitals performing cardiac surgery.

December 7, 2022

Transparency, public reporting, and a culture of change to quality and safety in cardiac surgery.

November 9, 2022

Outcome differences between surgeons performing first and subsequent coronary artery bypass grafting procedures in a day: a retrospective comparative cohort study.

June 29, 2022

Mortality due to hospital-acquired infection after cardiac surgery.

June 1, 2022

Fast tracking in cardiac surgery: is it safe?

May 11, 2022

Hospital-acquired functional decline and clinical outcomes in older cardiac surgical patients: a multicenter prospective cohort study.

March 2, 2022

Association between handover of anesthesiology care and 1-year mortality among adults undergoing cardiac surgery.

March 2, 2022

A theoretical model of flow disruptions for the anesthesia team during cardiovascular surgery.

September 22, 2021

Outcomes from Wake Up Safe, the pediatric anesthesia quality improvement initiative.

February 3, 2021

A systems approach to analyzing and preventing hospital adverse events.

June 24, 2020

Independent Mortality Review of Cardiac Surgery at St George’s University Hospitals NHS Foundation Trust.

April 15, 2020

Preventable closed claims in the AANA Foundation closed malpractice claims database.

February 12, 2020

Cognitive engineering to improve patient safety and outcomes in cardiothoracic surgery

December 4, 2019

Starting elective cardiac surgery after 3 pm does not impact patient morbidity, mortality, or hospital costs.

November 6, 2019

Doctors were alarmed: would I have my children have surgery here?

June 12, 2019

Failure to debrief after critical events in anesthesia is associated with failures in communication during the event.

March 20, 2019

Evaluation of an electronic health record structured discharge summary to provide real time adverse event reporting in thoracic surgery.

March 13, 2019

Trends in anesthesia-related liability and lessons learned.

March 6, 2019

Association of overlapping surgery with patient outcomes in a large series of neurosurgical cases.

November 22, 2017

Surgical Patient Safety: A Case-Based Approach.

October 18, 2017

Team-based care: the changing face of cardiothoracic surgery.

October 11, 2017

Outcomes of concurrent operations: results from the American College of Surgeons' National Surgical Quality Improvement Program.

October 11, 2017

Perception of safety of surgical practice among operating room personnel from survey data is associated with all-cause 30-day postoperative death rate in South Carolina.

August 16, 2017

Double-booked: when surgeons operate on two patients at once.

July 26, 2017

Comparison of appendectomy outcomes between senior general surgeons and general surgery residents.

May 3, 2017

Global patient outcomes after elective surgery: prospective cohort study in 27 low-, middle- and high-income countries.

December 7, 2016

Computer-assisted process modeling to enhance intraoperative safety in cardiac surgery.

October 19, 2016

See More About The Topic

Operating Room

Health Care Providers

Risk Managers

Cardiothoracic Surgery

Surgical Complications

Probabilistic risk assessment of accidental ABO-incompatible thoracic organ transplantation before and after 2003.

Pharmacist-led mobile health intervention and transplant medication safety: a randomized controlled clinical trial.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Probabilistic risk assessment of accidental ABO-incompatible thoracic organ transplantation before and after 2003.

Pharmacist-led mobile health intervention and transplant medication safety: a randomized controlled clinical trial.

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