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Perspectives on Safety > Perspective
with commentary by Susan Burnett and Charles Vincent, PhD, International Perspectives on Safety, May 2007
The dangers of health care in Britain have been long understood. Systematic data collection of the hazards of health care can be traced back at least to the time of Florence Nightingale's publications in the 1860s. In this short paper, we outline the evolution of patient safety and trace its development and progress over the last 10 years in Britain, where a nationalized health service and sustained commitment from Chief Medical Officer Sir Liam Donaldson and other senior figures have brought patient safety to considerable prominence.
The Medication Errors Panel. Sacramento, CA: California State Senate; March 2007.
This report shares findings from an expert panel convened to study the causes of medication error in the outpatient setting and provide recommendations for reducing errors associated with prescription and over-the-counter medications.
Journal Article > Review
Journal reporting of medical errors: the wisdom of Solomon, the bravery of Achilles, and the foolishness of Pan.
Murphy JG, Stee L, McEvoy MT, Oshiro J. Chest. 2007;131:890-896.
The authors discuss medical errors, motivations for error reporting, and barriers to publication regarding mistakes. They suggest a model for sharing errors via peer-reviewed methods.
Woodcliff Lake, NJ: Drug Topics; 2007.
This podcast features a panel discussion on prescription drug errors with pharmacy experts, including Michael Cohen.
Journal Article > Commentary
Larsen D, Cole R, Higton P. Nurs Stand. 2007;21:35-40.
By introducing several scenarios that illustrate the effective use of a decision-making tree, the authors emphasize the importance of fair response to medication error at both the individual and system levels.
McCoy K, Brady E. USA Today. February 11, 2008:A1.
This series of investigative articles uncovers the factors involved in pharmacy errors, relates stories of patients harmed by such errors, and includes steps that consumers can take to minimize their risk.
Journal Article > Study
Smits M, Zegers M, Groenewegen PP, et al. Qual Saf Health Care. 2010;19:e5.
This study analyzed more than 700 adverse events in order to identify latent causes of errors.
Rosenbaum L. The New Yorker: Elements. August 20, 2013.
This magazine article relates the risks and benefits associated with the 2003 resident work hour limits.
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; November 2010. Report No. OEI-06-09-00090.
Hospitalized patients continue to suffer iatrogenic harm, according to this study of Medicare patients completed by the Office of the Inspector General (OIG). Using methodology similar to the landmark Harvard Medical Practice Study, this study found that 13.5% of hospitalized Medicare patients experienced an adverse event, of which nearly half were considered preventable. However, fewer than 2% of patients experienced either a never event or a preventable complication for which hospitals are no longer reimbursed by the Centers for Medicare and Medicaid Services. These results are similar to the OIG's prior 2008 report. Based on these results, OIG recommends further efforts to accurately measure adverse events, and also recommends broadening the "no pay for errors" policy. The challenges of accurately measuring safety problems are discussed in an AHRQ WebM&M commentary.
Jt Comm J Qual Patient Saf. 2016;42:243-264.