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Journal Article > Study
Iatrogenic events resulting in intensive care admission: frequency, cause, and disclosure to patients and institutions.
Lehmann LS, Puopolo AL, Shaykevich S, Brennan TA. Am J Med. 2005;118:409-413.
This prospective observational study from four Boston teaching hospitals reports on the characteristics of patients admitted to intensive care units as the result of iatrogenic events.
Special or Theme Issue
Baker GR, ed. Healthc Q. 2005;8:1-156.
This special issue highlights Canadian experiences in several safety-related areas: culture shift in support of safety, risk identification and reduction, medication safety, change initiative strategies, and disclosure and accountability.
Sipkoff M. Drug Topics (Health-System Edition). August 21, 2006.
This article discusses a decimal error that resulted in a tenfold overdose of an analgesic and how this common drug administration error could easily be eliminated.
Journal Article > Study
Burroughs TE, Waterman AD, Gallagher TH, et al. Jt Comm J Qual Patient Saf. 2007;33:5-14.
Prior research has shown that patients are concerned about medical errors and desire full disclosure of errors when they occur. However, patients' perceptions of what constitutes an error may differ from health care providers' perceptions. This study surveyed more than 1600 patients recently discharged from 12 hospitals to determine what patients considered to be an error and to evaluate patients' perception of their safety during their recent hospitalization. Patients defined "error" more broadly than traditional definitions, including such issues as falls, communication problems, and perceived lack of attentiveness by providers. Although nearly all patients felt safe overall, 39% experienced at least one error-related concern during their hospitalization, most commonly due to well-recognized problems such as medication errors. The authors recommend incorporating such patient views into patient-centered safety programs.
Journal Article > Commentary
Kahn JS. JAMA. 2015;313:2427-2428.
Being accountable for errors and working to learn from them is key to improving patient safety. This commentary describes a physician's reactions following a medication ordering error that resulted in temporary patient harm, steps taken to report the error, how the incident was used as a teaching point for team members, and the patient's positive response to the physician's disclosure and apology.