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Cases & Commentaries
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Mark A. Rosen, MD; November 2003
Due to the delay in anesthesiology becoming available for an urgent C-section, an infant is delivered with profound neurologic abnormalities.
Journal Article > Commentary
Spear SJ. Harv Bus Rev. September 2005;83:78-91.
This commentary provides a broad overview of the issues facing health care systems in their efforts to promote quality and safety. The author discusses pervasive cultural barriers and process limitations that contribute to errors, while providing a series of anecdotes to demonstrate how easy and frequent these events can occur. Approaches for improvement that draw from the experiences of non-health care organizations, such as Toyota, are included. The strength of the commentary lies in the compelling stories shared and the perspectives offered to foster change.
Journal Article > Study
Improving communication and resolution following adverse events using a patient-created simulation exercise.
Gallagher TH, Etchegaray JM, Bergstedt B, et al. Health Serv Res. 2016;51(suppl 3):2537-2549.
Communication-and-resolution programs emphasize early disclosure of adverse events to patients and families, but implementing this patient-centered approach can be challenging. Researchers found that simulation was useful in helping stakeholders understand what patients and families experience after an adverse event and suggest that such understanding might lead to improved response.