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- Alert fatigue 3
- Device-related Complications 53
- Diagnostic Errors 98
- Discontinuities, Gaps, and Hand-Off Problems 74
- Drug shortages 13
- Failure to rescue 3
- Fatigue and Sleep Deprivation 17
- Identification Errors 47
- Interruptions and distractions 3
- Delirium 1
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- MRI safety 1
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- Psychological and Social Complications 71
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United States of America
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Search results for "Patients"
Gawande A. The New Yorker. 1999;74:40-55.
Gawande uses a harrowing personal example of a medical error to illustrate that medical mistakes are not a problem of bad physicians. He contends that virtually everyone who cares for hospitalized patients will make serious mistakes every year. Gawande attacks the current medical malpractice system, stating that it creates an environment of silence and fear and makes patients and physicians adversaries. He describes the current forum used by physicians to process medical errors, the Morbidity and Mortality Conference, and points out that its major limitation is highlighting individual error, not the process or system that allowed or led to the error. Gawande outlines the steps taken by the field of anesthesia to analyze errors and find remedies for system failure.
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.
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.
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.
Belkin L. New York Times Magazine. June 15, 1997;sect 6:28-33, 44, 50, 63, 66, 70.
In this article, Belkin examines how the medical field has recently shifted away from blaming individuals for medical error toward a model that searches for systems problems and solutions for prevention. The author describes the human factors approach to medical errors and tells the stories of several victims of tragic medical errors, including steps that providers and institutions have implemented to improve their systems and prevent recurrences of such events.
Audiovisual > Audiovisual Presentation
Solana Beach, CA: Bridge Medical; 1997.
Used by countless health care organizations as an orientation tool for staff on patient safety, Beyond Blame neatly encapsulates the myriad of issues involving medical error, its impact on the practitioner, and why change needs to take place to make care safer. Personal stories from frontline practitioners, pharmacy administrators, and health care leaders effectively illustrate the aftermath of mistakes and the need for improving patient safety.
Millenson ML. Chicago, IL: University of Chicago Press; 1997.
Millenson, a Pulitzer-nominated former health care writer, discusses the health care quality movement and the increasingly important role of information technology in both measuring and promoting quality. He covers a broad range of topics in a somewhat journalistic tone, from quality assessment to evidence-based medicine, from accountability to pay-for-performance. Although the book is nearly a decade old, it remains important for having laid out a vision for the use of information and computerization in assessing and promoting quality. Although the book includes sections on patient safety, its strengths are those on quality assessment and improvement.
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.
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.
Reason JT. New York, NY: Cambridge University Press; 1990.
Despite writing almost nothing specifically on health care, clinical psychologist James Reason has influenced modern thinking about medical errors more than any other individual. This book shows why. Although some of the information on error analysis and theory may be too technical for the average reader, Reason's lucid explanations of complex concepts, his easily accessible examples, and his wry sense of humor make this a must-read for those interested in learning safety theory. His book Managing the Risks of Organizational Accidents is less theoretical and may be more appropriate for the reader interested in an introduction to Reason's thinking.
Mills DH, ed. Report on the medical insurance feasibility study / sponsored jointly by California Medical Association and California Hospital Association. San Francisco, CA: Sutter Publications, Inc.; 1977.
Escalating professional liability costs prompted this study on the nature of adverse outcomes related to medical care. Findings showed that incident rates were low, but also that risks were a part of medical care, and not all of them were associated with legal fault. In addition, the resulting work provided an initial set of classifications, nomenclature, and evaluation techniques that were seen by the authors to assist in creating a more efficient patient compensation program. (A summary of the report was published as Mills DH. Medical insurance feasibility study. A technical summary. West J Med. 1978;128:360-365.)