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Finkelstein JB. American Medical News; January 3/10, 2005.
States can find themselves in a position to make progress on patient safety in ways that limit the federal government. Stories of their successful efforts provide effective examples for national initiatives.
ISMP Medication Safety Alert! Acute Care Edition. December 16, 2004;9:1-2.
Gawande A. The New Yorker. December 6, 2004;82-91.
A sensitive portrayal of the challenges in defining quality and implementing change even when practitioners are committed to high-quality care.
Swidey N. Boston Globe. January 4, 2004.
An introduction to Donald Berwick, CEO of Boston's Institute for Healthcare Improvement, and his vision for reshaping health care to improve patient safety and quality.
ISMP Medication Safety Alert! Acute Care Edition. May 2, 2001.
This is an alert from the Institute for Safe Medication Practices informing readers of a fatal medication error that occurred because of a misinterpreted decimal point. The error involved administration of morphine to a 9-month-old infant who received 5 mg instead of 0.5 mg of the drug. The order did not include a zero before the decimal point, and the nurse filling the order overlooked the omission. The child suffered a cardiac arrest and died. The case illustrates the importance of clearly communicating information about medications.
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.
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.