… … Mercer K, Carter C, Burns C, et al. Including the reason for use on prescriptions sent to pharmacists: scoping …

… A, Ho JM, et al. Prescribers' perspectives on including reason for use information on prescriptions and medication …

… heart-lung transplant error in 2003. … Cook RI, Wreathall J, Smith A, et al. Probabilistic risk assessment of …

The authors report on the results of a consensus conference that focused on safety for patients with diabetes and other endocrine diseases. They list the recommendations from the multidisciplinary expert panel convened for the conference.

The author discusses concepts of human error, contrasting the person approach with a system approach in understanding the differing philosophies of error management. The person approach focuses on blaming individuals, whereas the system approach concentrates on the conditions under which individuals work. The author further explains several background concepts, including the “Swiss cheese” model of system accidents, the components of error management, and the principles of becoming a high-reliability organization. He explains the benefits of making the transition from a person approach to a system approach in the context of a high-reliability organization. This article is from a British Medical Journal special issue on patient safety.

This review discusses the importance of human factors research in reducing adverse events. Drawing from experiences in cardiac surgery, the authors detail the process of capturing and examining various error types. They use case examples to illustrate specific incidents and demonstrate the utility of a systems approach to uncover solutions. The authors also share lessons learned from exploring similar high-complexity industries. They suggest that the profession must better refine methods for prospective analysis of surgical performance and for retrospective analysis of near misses and critical incidents.

… of anaesthesia = Journal canadien d'anesthesie … Can J Anaesth … Using methods to investigate disasters such as …

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.