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Journal Article > Commentary
Roter DL, Wolff J, Wu A, Hannawa AF. BMJ Qual Saf. 2017;26:508-512.
Effective team communication is a key component of safe care. This commentary discusses the role of patient–family partnerships in enhancing health care safety in ambulatory and home settings. The authors describe a communication intervention to improve patient and family collaboration during ambulatory care visits. Components of the approach included engaging family participation in routine visits and coaching them to ask questions.
Lerner BH. The Washington Post. November 28, 2006:HE01.
The author reviews the legacy of Libby Zion and how her untimely death raised awareness of the impact that resident duty hours and fatigue could have on patient care and quality.
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.
Dobbs D. New York Times Magazine. April 24, 2005;sect 6:40.
The author interviews experts who discuss the autopsy as a unique method for discovering medical mistakes and why it is not used more often as a teaching and improvement mechanism.