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Perspectives on Safety > Interview
Patient Safety Programs, July 2006
Allan Frankel, MD, is Director of Patient Safety for Partners HealthCare, the merged entity of Harvard hospitals and clinics that includes Massachusetts General and Brigham and Women's Hospital. Dr. Frankel, an anesthesiologist by training, has been a key member of the faculty of the Institute for Healthcare Improvement, co-chairing numerous Adverse Drug Events and Patient Safety Collaboratives. Dr. Frankel's work in patient safety focuses on leadership training, high reliability in health care, teamwork development, and cultural change. We asked Dr. Frankel to speak with us about developing a comprehensive patient safety program.
Journal Article > Study
Error or "act of God"? A study of patients' and operating room team members' perceptions of error definition, reporting, and disclosure.
Espin S, Levinson W, Regehr G, Baker GR, Lingard L. Surgery. 2006;139:6-14.
This study discovered both similarities and differences in the way surgeons, nurses, anesthesiologists, and patients responded to four scripted clinical error scenarios. Findings suggested that all groups incorporated a negative outcome or a deviation from standard of practice into their error definition rather than analyzing the event independent of those factors. In addition, noted differences existed between patients who supported reporting for all negative events and nurses who believed in selective reporting. Similarly, persistent gaps existed between the full disclosure patients expect and the partial disclosure health professionals believe should occur. While the study represents a small sample size from two tertiary institutions, it does emphasize the importance of a safety culture and the need to redefine errors as opportunities for learning and improvement rather than individual or isolated events.
Journal Article > Review
Fettes PD, Jansson JR, Wildsmith JA. Br J Anaesth. 2009;102:739-748.
This review surveys common risks involved with spinal anesthesia and describes strategies to minimize errors and address failures when they occur.
Journal Article > Commentary
Brandom BW, Callahan P, Micalizzi DA. Paediatr Anaesth. 2011;21:730-736.
This commentary reveals a personal story of loss and discusses how practitioners and family members need support following adverse events.
Journal Article > Review
The disclosure of unanticipated outcomes of care and medical errors: what does this mean for anesthesiologists?
Souter KJ, Gallagher TH. Anesth Analg. 2012;114:615-621.
This review discusses how educating anesthesiologists about risk management and error disclosure can improve patient safety in anesthesiology.
Lantz F. WBUR. August 15, 2017.
Partnerships between physicians and patients can yield important outcomes that support safety improvements. This radio segment reports insights from both the patient and clinician involved in an adverse event and how this incident launched an organization that focuses on support for patients and clinicians that have been affected by medical errors.