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- Communication Improvement 1
- Culture of Safety 1
- Education and Training 2
- Error Reporting and Analysis
- Human Factors Engineering 1
- Legal and Policy Approaches 1
- Logistical Approaches 1
- Quality Improvement Strategies 2
- Technologic Approaches 1
- Diagnostic Errors 1
- Discontinuities, Gaps, and Hand-Off Problems 2
- Medical Complications
- Medication Safety 3
- Surgical Complications 3
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Journal Article > Study
Chan DK, Gallagher TH, Reznick R, Levinson W. Surgery. 2005;138:851-858.
This study evaluated the capacity of 30 academic surgeons to discuss error scenarios, such as wrong-side surgery and retained sponges, with standardized patients. Investigators analyzed the conversations and discovered that 57% of the surgeons used the word "error" or "mistake," but less than half offered a verbal apology. The authors conclude that significant gaps exist between how physicians disclose medical errors and what patients expect in such conversations, thereby generating a need for educational intervention. The same authors previously wrote a commentary calling for professional action in disclosure of medical errors.
Inspiring Ideas and Celebrating Successes: A Guidebook to Leading Patient Safety Practices in Ontario Hospitals.
OHA Patient Safety Support Service. Toronto, Ontario, Canada: Ontario Hospital Association; 2006.
This report shares successful patient safety strategies employed in Ontario hospitals to address medication safety, patient incident management, infection issues, and administrative process improvements.
Talaga T, Cribb R. Toronto Star. March 19, 2007.
This article discusses disclosure of medical errors and shares stories from several Canadian hospitals on their policies for disclosing adverse events.
Ottawa, ON, Canada: Canadian Institute for Health Information; August 14, 2007.
Using survey data as well as information on patient safety indicators, this report provides an update on the frequency of certain types of errors and incidents in Canada.
Journal Article > Study
Self-reported medical, medication and laboratory error in eight countries: risk factors for chronically ill adults.
Scobie A. Int J Qual Health Care. 2011;23:182-186.
Improving patient safety in the ambulatory setting requires the development of new care models, greater utilization of information technology, and a focus on patient factors such as health literacy. Current health policy reform often debates the virtues of international care delivery models as a driver for change. Building on past Commonwealth Fund reports, this study surveyed patients with self-reported chronic disease in eight countries to identify risk factors associated with self-reported errors. Investigators found that errors were associated with a number of factors, including a patient's age, education level, and prescription drug use. The three risk factors with the greatest relationship to errors were experiencing a care coordination problem, having seen four or more doctors within the past 2 years, and having used the emergency department in the last 2 years. The authors advocate for improved sharing of clinical information (e.g., electronic health records) and specific policy and practices designed to improve care coordination.