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- Perspectives on Safety 2
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- Device-related Complications 8
- Diagnostic Errors 5
- Discontinuities, Gaps, and Hand-Off Problems 8
- Failure to rescue 1
- Fatigue and Sleep Deprivation 2
- Identification Errors 1
- Medical Complications 10
- Medication Safety 10
- Nonsurgical Procedural Complications 3
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- Psychological and Social Complications 11
- Surgical Complications 5
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- Medicine 48
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Cases & Commentaries
- Web M&M
Bryan A. Liang, MD, PhD, JD; May 2004
Understanding that she may lose her life without it, a woman severely injured in a collision rejects a blood transfusion for religious reasons. However, her parents persuade the physicians otherwise, and the woman lives.
Cases & Commentaries
- Web M&M
Glenn Flores, MD; April 2006
With no one to interpret for them and pharmacy instructions printed only in English, nonEnglish-speaking parents give their child a 12.5-fold overdose of a medication.
Perspectives on Safety > Perspective
Organizational Change in the Face of Highly Public Errors—I. The Dana-Farber Cancer Institute Experience
with commentary by James B. Conway; Saul N. Weingart, MD, PhD, Errors in the Media and Organizational Change, May 2005
A decade ago, two tragic medical errors rocked one of the world’s great cancer hospitals, Dana-Farber Cancer Institute (DFCI) in Boston, to its core. The errors led to considerable soul searching and, ultimately, a major change in institutional practices a...
Perspectives on Safety > Interview
The Patient's Role in Safety, March 2007
Sorrel King is the mother of Josie King, who died tragically in 2001 at age 18 months because of medical errors during a hospitalization at Johns Hopkins Hospital. She has subsequently become one of the nation’s foremost patient advocates for safety, forming an influential foundation (the Josie King Foundation) and partnering with Johns Hopkins to promote the field of patient safety around the world.
van Vuuren W. [dissertation]. Eindhoven, The Netherlands: Eindhoven University of Technology; 1998.
This report provides a detailed review of risk management in complex and high-risk organizations. The author focuses on the analysis and categorization of safety-related incidents and their organizational causes.
Meisel Z. Slate. November 8, 2005.
In this article, an emergency medicine physician describes the work environment of emergency medical technicians and paramedics and why it is prone to error.
A Consensus Statement of the Harvard Hospitals. Burlington: Massachusetts Coalition for the Prevention of Medical Errors; 2006.
This consensus paper of the Harvard-affiliated hospitals was prepared by clinicians, risk managers, and patients to provide an in-depth understanding of preventable adverse events, their impact on patients, families, and providers, and how to manage such events. The report provides detailed guidelines based on the premise that all care should be safe and patient-centered and that all actions require full disclosure. In addition to offering recommendations on how to effectively communicate with patients and families, the report discusses support for caregivers and a detailed strategy for institutions to respond to such events in a timely and appropriate fashion. Finally, the comprehensive report offers several appendices that include recommendations and a case study on communicating with patients and families.
Washington, DC: CCM, Inc.; 2006. Crawford-Mason C (producer), Dobyns L (reporter); Management Wisdom Video Series.
This documentary reports on the experiences of a large health care system's success in adopting a systems approach to improving care, reducing costs, and saving lives. The program will air on PBS stations after April 1, 2006; check local stations for dates and times. (Note: This summary is based on information from the producers; a copy of the documentary was not available for preview).
Stout D. New York Times. June 17, 2006;National desk:9.
This article reports on the investigation following the death of New York Times reporter David E. Rosenbaum. The investigation uncovered a range of failures in emergency care and is described in a report available via the link below.
Davies T. Washington Post. September 22, 2006.
This article reports on the deaths of three infants from heparin overdoses and describes how the hospital community has responded to the errors.
Feinmann J. The Independent. November 14, 2006.
This article reports on a husband's investigation into his wife's death following a routine surgery and his subsequent efforts to bring human factors training to National Health Service hospitals.
"Eye to Eye with Katie Couric." CBS News Video. February 6, 2007.
Dr. Berwick, President and CEO of the Institute for Healthcare Improvement, shares his insights on why health care is difficult to fix and his optimism that systems can be changed to reduce, and even eliminate, medical error.
Breast Cancer Services in Trafford and North Manchester. An Investigation Into The Circumstances Surrounding A Serious Clinical Incident In Symptomatic Breast Services – The Baker Report.
Baker M. Manchester, England: NHS North West; February 2007.
This report shares findings from an investigation into individual and system failures that contributed to a radiologist misreading mammograms for a 2-year period.
Victoria Times Colonist. March 26, 2007.
This article reports on findings from an investigation into hospital-acquired infections in British Columbia.
Urbina I, Nixon R. New York Times. March 30, 2007;National Desk section:1.
This article reports on the inconsistent use of the Department of Defense electronic medical records system and how this has led to medical errors and delays in care for US veterans.
Landro L. Wall Street Journal. April 4, 2007:D5.
This article reports on initiatives to standardize the color designations of color-coded wristbands to avoid confusion and reduce the risk of error.
US News & World Report. July 3, 2008.
This article discusses the findings of a recent study that reported deficiencies in barcode systems requiring numerous overrides and "workarounds" by nurses.
Berens MJ, Armstrong K. Seattle Times. November 16-18, 2008.
This three-part journalistic investigation highlights efforts in Washington State to track and minimize the spread of methicillin-resistant Staphylococcus aureus (MRSA) and to address organizational resistance to changes needed to mitigate the problem.
Rein L. Washington Post. July 21, 2009:E1.
This news article reports on Washington, DC–area initiatives to track preventable patient injury and discusses strategies to hold hospitals accountable to reduce the number of avoidable incidents.
Bogdanich W. New York Times. January 24, 2010:A1.
First in a series on medical radiation, this news feature and accompanying video investigate patient deaths and injuries following mistakes related to radiation treatment. The journalists discuss the number of radiation therapy errors in New York and reveal that state law does not require public reporting of such mistakes.