Narrow Results Clear All
- Journal Article 1
- Slideset 1
- Legislation/Regulation 15
- Special or Theme Issue 4
- Toolkit 12
- Web Resource 110
- Bibliography 2
- Grant 1
- Meeting/Conference 13
- Press Release/Announcement 2
Communication between Providers
- Sbar 1
- Communication between Providers 40
- Culture of Safety 87
Education and Training
- Students 2
Error Reporting and Analysis
- Error Reporting 64
Human Factors Engineering
- Checklists 10
- Legal and Policy Approaches 57
- Logistical Approaches 18
- Policies and Operations 1
Quality Improvement Strategies
- Benchmarking 24
- Research Directions 7
- Specialization of Care 11
- Teamwork 28
- Clinical Information Systems 20
- Transparency and Accountability 8
- Device-related Complications 10
- Diagnostic Errors 23
- Discontinuities, Gaps, and Hand-Off Problems 29
- Drug shortages 3
- Failure to rescue 1
- Fatigue and Sleep Deprivation 3
- Identification Errors 10
- Medical Complications 47
- Medication Errors/Preventable Adverse Drug Events 42
- Nonsurgical Procedural Complications 9
- Overtreatment 4
- Psychological and Social Complications 26
- Surgical Complications 41
- Transfusion Complications 1
- Ambulatory Care 71
- General Hospitals 39
- Long-Term Care 10
- Outpatient Surgery 10
- Patient Transport 1
- Psychiatric Facilities 4
- Allied Health Services 1
- Internal Medicine 104
- Pediatrics 10
- Primary Care 20
- Nursing 21
- Pharmacy 28
- Family Members and Caregivers 15
- Health Care Executives and Administrators 319
Health Care Providers
- Nurses 29
- Pharmacists 17
- Physicians 65
Non-Health Care Professionals
- Educators 20
- Media 8
- Patients 72
- Africa 1
- Asia 1
- Australia and New Zealand 4
- Europe 89
- Canada 13
United States of America
United States Federal Government
- Department of Health and Human Services (HHS) 64
- United States Federal Government 78
Search results for "Health Care Providers"
- Health Care Providers
Deming WE. Cambridge, MA: The MIT Press; 2000.
Deming believes that American companies need to transform their method of management to engage and compete successfully. In Out of the Crisis, originally published in 1986, Deming presents his classic theory based on his 14 Points for Management. Deming provides a distinct emphasis on the role of leadership to generate the change required for American business to remain vital. His thoughts on how to change management thinking in order to achieve success have been applied to the health care quality movement.
Kohn L, Corrigan J, Donaldson M, eds. Washington, DC: Committee on Quality of Health Care in America, Institute of Medicine. National Academies Press; 1999. ISBN: 9780309068376.
One measure of the impact of this report, the first in the series of reports by the Institute of Medicine (IOM) on the quality of health care in the United States, is that one can still refer to ''The IOM Report'' and everyone will recognize the reference to To Err is Human (despite the fact that, as of this writing, the IOM has released approximately 250 reports since To Err). In fact, many argue that the modern field of patient safety began with this report's publication. Although the report has been criticized for its strong focus on medication errors and computerized order entry (to the exclusion of other safety concerns) and the relatively limited discussion of the impact of the malpractice system, there is no mistaking its impact. Perhaps its most famous contribution was the extrapolation of the Harvard Medical Practice Study data and the Utah and Colorado Medical Practice Study data, which led to the famous estimate of 44,000 to 98,000 deaths per year from medical errors (the equivalent of a jumbo jet a day). Whether one believes these numbers or not, it is clear that the IOM report was essential in placing the issue of medical mistakes on the public and professional agenda.
Scheffler A, Zipperer LA, eds. Chicago, IL: National Patient Safety Foundation; 1999.
The proceedings from the 1998 Annenberg meeting hosted in Rancho Mirage, California.
Perrow C. Princeton, NJ: Princeton University Press; 1999. ISBN: 0691004129.
Though less often cited than high-reliability theory in the health care literature, normal accidents theory is equally prominent in the study of complex organizations. A more pessimistic view, normal accidents theory suggests that, in some settings, a major accident becomes almost inevitable. Perrow identifies "complexity" and "tight coupling" as the two factors that create an environment in which a major accident becomes more rather than less probable over time, regardless of steps taken to increase safety. The degree of complexity Perrow has in mind occurs when no single operator can immediately foresee the consequences of a given action in the system. Tight coupling occurs when processes are intrinsically time-dependent: once a process has been set in motion, it must be completed within a certain period of time. Many health care organizations would meet Perrow's definition of complexity, but only hospitals would be regarded as exhibiting tight coupling. Nuclear power provides the archetypal complex, tightly coupled system, and an analysis of the near disaster at Three Mile Island provides the centerpiece of the book. Even if one does not share Perrow's conclusion about the potential for catastrophe as an intrinsic property of certain complex systems, the case studies offer many fascinating insights into the possible failure modes for complex organizations, including hospitals.
The Report of the Manitoba Pediatric Cardiac Surgery Inquest: An Inquiry into Twelve Deaths at the Winnipeg Health Sciences Center in 1994.
Sinclar M. Provincial Court of Manitoba, CA.
A 3-year review investigating a series of deaths from a pediatric cardiac unit revealed flaws in the recruitment process, quality assurance mechanisms, treatment of nurses, staffing, and lines of authority. The report offers recommendations for necessary quality improvements.
Cook RI, Woods DD, Miller C. Chicago, IL: National Patient Safety Foundation; 1998.
A report from a workshop, this document is a well-written look at the differences between "first stories" and "second stories" describing major errors. First stories are the easy one-person or one-cause accounts and reactions to critical incidents. "So-and-so forgot to check the patient's allergy history." Or "How could they have ignored the alarm and so many other red flags?" Even now, with some penetration of the concepts of systems thinking, it is still easy to fall back on the familiar and easy explanation of human error, missing key opportunities to fix underlying problems with processes of care or the way care is organized. Identifying such problems, however, requires the far richer "second stories" about such critical incidents, and these stories do not emerge without hard work. The authors have done this hard work for many publicized medical errors, drawing on follow-up newspaper articles and other investigative documents, often in far more obscure places than headlining first stories. Even readers familiar with root cause analysis will likely find value in many of the case studies. And, for those not familiar with such accident investigation techniques, the report provides a very readable introduction to their importance and a resource for further references.
Helmreich RL, Merritt AC. Aldershot, Hampshire, England: Ashgate; 1998.
This book examines the influence of professional, national, and organizational cultures on shaping individual attitudes, values, and team interactions in both aviation and medicine. The research comes largely from research on culture and teamwork in aviation, but the intended audience clearly includes those interested in error reduction in health care, and many of the cases and vignettes discussed come from medicine. In recent years, the importance of teamwork and organizational culture has gained increasing attention within health care, especially within patient safety. This book provides an introduction to these topics and also contains ample material that will likely be new for those already familiar with the area.
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.
Leape LL, Kabcenell A, Berwick DM, Roessner J. Boston, MA: Institute for Healthcare Improvement; 1998.
This application-oriented book provides the results of the Institute for Healthcare Improvement (IHI) Breakthrough Series program focusing on decreasing adverse drug events in health care facilities. More than 40 organizations share their collective learning experience, from planning for improvement, testing ideas, studying what they learned, and implementing change. The book’s numerous case studies, descriptions of step-wise improvement processes, and strategies for breaking down organizational barriers help illustrate the experience and methods that led to the group’s success. The book will be valuable to individuals and institutions attacking the problem of medication errors or seeking insight into collaborative learning models.
Casey SM. Santa Barbara, CA: Aegean Publishing Company; 1998. ISBN 13: 9780963617880.
This book introduces important human factors issues using a series of real cases and incidents from health care and a variety of other industries. The title refers to the disastrous death of a patient due to a design flaw in the radiotherapy accelerator, Therac-25. A plausible but unanticipated series of keystrokes by the operator resulted in the delivery of more than 100 times the intended dose of radiation. Other chapters discuss events as diverse as the Union Carbide disaster in Bhopal, India, an incorrect stock trade that nearly caused a market collapse, a variety of military and industrial examples, as well other cases from health care. The book provides numerous real-world examples of misadventures in human–system interactions.
Klein G. Cambridge, MA: MIT Press; 1998.
Morell RC, Eichhorn JH, eds. New York, NY: Churchill Livingstone; 1997. ISBN: 9780443076824.
Anesthesiology made its mark early on in the quest for patient safety. Eichhorn was a part of the convergence that resulted in successful change in that specialty in the 1970s. He and Morell are well suited to be at the helm of the first anesthesia textbook on patient safety. The book opens with a recap on anesthesia's historic involvement in achieving and sustaining safety improvements. In addition, authors provide clinical guidance on topics such as positioning and airway algorithms and the use of simulators as training environments. A variety of solutions are provided to support continued success in this highly technical area of medicine.
The Girl Who Died Twice: Every Patient's Nightmare: the Libby Zion Case and the Hidden Hazards of Hospitals.
Robins NS. New York, NY: Delacorte Press; 1995. ISBN 0385308094.
Robins, an investigative journalist, recounts the story of Libby Zion, who died at New York Hospital in 1984 allegedly at the hands of under-supervised and overworked residents. The book is an interesting and engaging account of a case and its aftermath, including the highly publicized malpractice trial and the formation of the Bell Commission, which regulated resident work-hours for the first time. The book provides an important historical context for this case and the debate surrounding it, the implications of which are still being felt today in the wake of national regulations for resident duty-hours.
Bogner MSE. Mahwah, NJ: Lawrence Erlbaum Associates; 1994.
This book, published well in advance of the Institute of Medicine report To Err is Human, includes chapters by a number of leaders in their fields on a wide range of topics related to patient safety. Chapters include the Foreword by James Reason, Lucian Leape's chapter on the preventability of medical injury, the chapter Operating at the Sharp End by Richard Cook and David Woods, the chapter on team performance in the operating room by Robert Helmreich and Hans-Gerhard Schaefer, the chapter on the handling of fatigue in various industries by Gerald Krueger, David Gaba's chapter on human error in dynamic domains, and the Afterword by Jens Rasmussen.
Wolf ZR. Albany, NY: Delmar Publishing, Inc; 1994.
In one of the first professional books to deal with medication error from the nursing perspective, Wolf provides a comprehensive introduction to medication error for the nursing community, both students and seasoned practitioners alike. Topics covered include a student's experience with error, individual response to making a mistake, and the value of storytelling. The author provides solutions for dealing with error once it happens. The book closes with a teaching plan to help educate nurses about error reduction and a review of factors that contribute to medical mistakes in the nursing corps.
Cook RI, Woods DD. In: Bogner MS, ed. Human Error in Medicine. Hillsdale, NJ: Erlbaum and Associates; 1994:255-310.
The authors provide an introduction to systems failure and human error. They discuss these issues in light of how they affect large complex systems. Many of the examples are from anesthesiology, but the conclusions can be applied broadly throughout health care.
Sagan SD. Princeton, NJ: Princeton University Press; 1993.
Two competing paradigms dominate the study of the hazards associated with complex organizations. The more optimistic of these paradigms, high-reliability theory, focuses on organizations that have achieved exemplary safety records and identifies key factors contributing to these records, including a high priority for safety within the organization, significant levels of redundancy, decentralization of authority, and organizational learning. Normal accident theory takes a more pessimistic view by asserting that, with a certain degree of complexity and when processes are time dependent and tightly coupled, major accidents become almost inevitable. In fact, redundancy, decentralized decision making, and many specific safety measures may only increase the degree to which actions in one part of the system can produce unexpected, baffling effects in other parts of the system. Sagan sets out to test these two competing theories by answering the question: why has there never been an accidental nuclear war? The results of Sagan's detailed archival research initially appear to confirm the predictions of high-reliability theory. However, interviews with key personnel uncover several hair-raising near misses during the Cuban missile crisis. In fact, Sagan ultimately concludes that good fortune played a greater role than good design in the safety record of the nuclear weapons industry to date.
Gerteis M, Edgman-Levitan S, Daley J, Delbanco TL, eds. San Francisco, CA: Jossey-Bass; 1993. ISBN 9781555425449.
Authored by several leaders of the Picker/Commonwealth Program for Patient-Centered Care, this book demonstrates the broad impact of the program. The authors discuss the key tenets of patient-centered care, drawing on empirical research, theory, and results of many surveys of patients, providers, and administrators. The authors provide many practical suggestions, a number of which have been adopted since the book's first publication in 1993. Examples include giving patients access to their medical records, giving them ''written and/or visual information identifying members of the clinical team," and offering ''culturally sensitive educational materials tailored to specific ethnic groups.''
Paget MA. Philadelphia, PA: Temple University Press; 1988. ISBN: 0877225338.
In this often described landmark text on the nature of medical error, Marianne Paget uses a detailed series of physician interviews to illustrate the complexities of mistakes in medicine. She carefully describes the language associated with concepts such as mistake, fault, negligence, and blame. She provides a thoughtful and provocative analysis of these clinical events and probes how physicians think about their mistakes, including the associated psychological burden in confronting them. The large number of actual transcripts shared throughout her text creates opportunities to get inside the head of well-intentioned physicians who struggle with avoiding mistakes.
Senders JW, Morey NP. Hillsdale, NJ: Lawrence Erlbaum; 1991.