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- Error Reporting and Analysis
- Human Factors Engineering 1
- Logistical Approaches 1
- Quality Improvement Strategies 1
- Specialization of Care 1
- Teamwork 1
- Technologic Approaches 2
- Device-related Complications 1
- Diagnostic Errors
- Discontinuities, Gaps, and Hand-Off Problems 2
- Fatigue and Sleep Deprivation 1
- Delirium 1
- Medication Safety
- Transfusion Complications 1
Search results for "Diagnostic Errors"
Journal Article > Commentary
Dunn WF, Adams SC, Adams RW. Chest. 2008;133:1217-1220.
This case report describes how diagnostic and medication errors led to a temporary coma. The article features the views of both the patient and her husband, and an accompanying editorial discusses disclosing errors to patients.
Journal Article > Study
Smits M, Groenewegen PP, Timmermans DRM, van der Wal G, Wagner C. BMC Emerg Med. 2009;9:16.
Emergency department (ED) patients are particularly vulnerable to adverse events, and a prior study of closed malpractice claims implicated systems factors such as poor teamwork in adverse patient outcomes. This study used root cause analysis of incident reports to identify the types and causes of errors and unanticipated events in the ED. Incidents included poor communication and teamwork, particularly with other departments, but medication errors and diagnostic errors were also noted. The authors recommend that organizations integrate the ED into hospital-wide safety improvement efforts.
Journal Article > Study
Levtzion-Korach O, Alcalai H, Orav EJ, et al. J Patient Saf. 2009;5:9-15.
The limitations of standard incident reporting systems have been well documented. Although ubiquitous and relatively easy to use, such systems detect only a fraction of adverse events, are underused by physicians, and yield data that often are not analyzed or disseminated promptly. This analysis of data from a commercial, web-based system at an academic hospital confirms some prior concerns, but the authors were able to demonstrate that rapid review of reports resulted in specific system changes to improve workflow and safety. A prior article presented a framework for using incident reporting data to improve patient safety.
Gould M. Health Service Journal. September 15, 2008:22-24.
This article describes the state of general practitioner incident reporting in the United Kingdom.
Special or Theme Issue
Pediatr Crit Care Med. 2007;8(suppl):S1-S43.
This supplement covers issues related to safety indicators, fatigue, electronic medical records, infection, and disclosure of medical errors in the care of critically ill children.