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Perspectives on Safety > Perspective
with commentary by Jeffrey B. Cooper, PhD, Reflections on the History of the Patient Safety Movement, August 2006
My journey into patient safety began in 1972. It was born of serendipity enabled by the good fortune of extraordinary mentors, an environment that supported exploration and allowed for interdisciplinary teamwork, and my own intellectual curiosity. The...
Journal Article > Study
Rogers SO Jr, Gawande AA, Kwaan M, Puopolo AL, Yoon C, Brennan TA, Studdert DM. Surgery. 2006;140:25-33.
The authors identified 258 malpractice claims from 4 liability insurance companies where patients were harmed due to surgical error and reviewed these cases to determine the relative contribution of 17 "human factors" to the adverse event. Both individual and system factors contributed to errors, classified as cognitive errors, lack of technical competence or knowledge, communication breakdowns, patient-related factors, and others. The cases resulted in significant harm: 23% of the patients died, and 65% suffered disabling injuries. Most cases involved more than one clinician, and 31% involved multiple phases of care (eg, intraoperative and perioperative). The authors recommend researching methods to improve outcomes for less experienced surgical teams and reducing communication errors through structured signout and communication systems.