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Search results for "Health Care Executives and Administrators"
Manchester, UK: General Medical Council; June 2019.
Finding the appropriate balance between assigning criminality and accountability for tragic preventable patient harm is difficult. Summarizing a high-profile case in the United Kingdom that involved the death of a pediatric patient, misdiagnosis, and a senior pediatric trainee, this report explores elements of the criminality and accountability debate across the system and discusses policy, judicial, and individual components of a fair and just response to adverse events to keep organizations, clinicians, and patients safe.
Chicago, IL: American Board of Medical Specialties; 2016.
In response to the 2015 Improving Diagnosis in Health Care report, the National Patient Safety Foundation and American Board of Medical Specialties convened a multidisciplinary panel of patient safety experts to determine safety challenges in the diagnostic process as a way to inform recommendations for improving diagnosis. Their consensus focused on educational, assessment, and cultural aspects of the process.
Hoffman J, ed. Cambridge, MA: CRICO Strategies; 2014.
This analysis of more than 4700 diagnosis-related malpractice claims found that most errors occur in the ambulatory setting, involve lapses in clinical judgement, and result in missed diagnosis of cancer. The authors use the data to explore cognitive and process failures that contributed to diagnostic errors.
Berenson RA, Upadhyay D, Kaye DR. Washington, DC: Urban Institute. Princeton, NJ: Robert Wood Johnson Foundation; 2014.
This comprehensive policy brief emphasizes the importance of addressing diagnostic errors through health policy change. The report explores the role of missed and delayed diagnosis in malpractice claims and preventable harm to patients. The authors note the lack of attention to diagnosis in the seminal To Err is Human report. They outline several strategies to detect and characterize diagnostic errors, including patient and provider surveys, case review, voluntary reporting, claims review, audits, and trigger tools in electronic medical records. To enhance timely and accurate diagnoses, the report advocates for increasing research funding, greater government oversight, instituting formal diagnostic feedback mechanisms, and payment and medical education reform.
Geneva, Switzerland: World Health Organization; 2011.
This publication reports on the findings of the Latin American Study of Adverse Events, the first survey to explore the existence and impact of unsafe health care practices in the region.
Kingston-Riechers J, Ospina M, Jonsson E, Childs P, McLeod L, Maxted JM. Edmondton, AB, Canada: Canadian Patient Safety Institute; 2010. ISBN: 9781926541273.
This report analyzed patient safety in Canadian primary care practice to identify themes, priorities, gaps in research, and opportunities for improvement.
Breast Cancer Services in Trafford and North Manchester. An Investigation Into The Circumstances Surrounding A Serious Clinical Incident In Symptomatic Breast Services – The Baker Report.
Baker M. Manchester, England: NHS North West; February 2007.
This report shares findings from an investigation into individual and system failures that contributed to a radiologist misreading mammograms for a 2-year period.