Narrow Results Clear All
- Communication Improvement 5
- Culture of Safety 5
- Education and Training 4
- Error Reporting and Analysis 11
- Human Factors Engineering 7
- Legal and Policy Approaches 2
- Quality Improvement Strategies 6
- Teamwork 1
- Technologic Approaches 2
- Device-related Complications 1
- Diagnostic Errors 2
- Discontinuities, Gaps, and Hand-Off Problems 2
- Identification Errors 1
- Medical Complications 1
- Medication Safety 3
- Psychological and Social Complications 2
- Surgical Complications 1
- Health Care Executives and Administrators 15
- Health Care Providers 11
- Non-Health Care Professionals 9
- Patients 3
Search results for "Latent Errors"
Dekker S. Aldershot, UK: Ashgate Publishing; 2014. ISBN: 9781472439048.
This revised and reorganized book provides a primer on how human error causes mishaps and often illustrates deeper troubles within a system. Both the old view of human error that places blame on the individual and the new view that identifies most human failures as merely a symptom of systems-level problems are presented. This view of human error has led to the application of root cause analyses and human factors engineering in health care. New chapters discuss the importance of safety culture and provide recommendations on improving the failure investigation process.
Woods DD, Dekker S, Cook R, Johannesen L, Sarter N. Burlington, VT: Ashgate; 2010. ISBN: 9780754678335.
"Human error," the authors of this book argue, is an inherently misleading term. Drawing on the field of complexity science, the authors contend that viewing error as a definable and measurable entity fails to account for the complex social and organizational dynamics that allow errors to occur. In this viewpoint, approaches to improving patient safety that focus on measuring adverse events and limiting variability are inherently limited, as they only measure practitioners' behaviors and do not account for the organizational characteristics and influences that establish a culture of safety. The book uses insights from high-reliability organizations and the field of human factors engineering to establish a new paradigm for analyzing safety across a variety of industries.
Manchester, UK: General Medical Council; November 2014.
Hollnagel E. Aldershot, Hampshire, England: Ashgate; 2014. ISBN: 9781472423085.
Historically, the approach to patient safety has been more reactive rather than proactive, involving a response to adverse events and near misses after they occur. This book covers two perspectives of safety: a reactive approach that emphasizes reducing adverse outcomes and a proactive approach that focuses on ensuring actions go as planned. The author discusses how each approach has been applied in health care and other high-risk industries. A PSNet perspective explored what health care can learn from aviation, another high-risk industry.
Donchin Y, Gopher D, eds. New York, NY: CRC Press; 2013. ISBN: 9781466573628.
This publication uses case studies to explore human factors in health care and describes an approach to augment quality and prevent errors.
Harrisburg, PA: Patient Safety Authority; May 2019.
This report summarizes patient safety improvement work in the state of Pennsylvania and reviews the 2018 activities of the Patient Safety Authority, including the launch of the Center of Excellence for Improving Diagnosis, outreach programs, liaison efforts, and the convening of the first patient safety conference for the state.
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; November 2010. Report No. OEI-06-09-00090.
Hospitalized patients continue to suffer iatrogenic harm, according to this study of Medicare patients completed by the Office of the Inspector General (OIG). Using methodology similar to the landmark Harvard Medical Practice Study, this study found that 13.5% of hospitalized Medicare patients experienced an adverse event, of which nearly half were considered preventable. However, fewer than 2% of patients experienced either a never event or a preventable complication for which hospitals are no longer reimbursed by the Centers for Medicare and Medicaid Services. These results are similar to the OIG's prior 2008 report. Based on these results, OIG recommends further efforts to accurately measure adverse events, and also recommends broadening the "no pay for errors" policy. The challenges of accurately measuring safety problems are discussed in an AHRQ WebM&M commentary.
World Alliance for Patient Safety. Geneva, Switzerland: World Health Organization; 2008.
Through a discussion of a vincristine administration error, this booklet and video illustrate how system weaknesses can contribute to failure.
Cork, Ireland: Health Information and Quality Authority; March 21, 2008.
This report analyzes the findings of a diagnostic error investigation and provides numerous recommendations to improve standards for treating symptomatic breast disease.
Reason J. Farnham Surrey, UK: Ashgate; 2008. ISBN: 9780754674023.
The British psychologist James Reason's insights into the nature of human error and systems theory, which include the ''Swiss Cheese'' model of accident causation, constitute the fundamental underpinning of the patient safety movement. In this book, Reason discusses approaches to managing complex hazardous systems—including healthcare—and achieving high reliability. Through an examination of the causes of human and organizational errors, as well as singular cases of heroic recovery from errors, this book expands upon the ground covered in Reason's two other classic texts, Human Error and Managing the Risks of Organizational Accidents.
Toronto, ON, Canada: Institute for Safe Medication Practices Canada. April 30, 2007.
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.
A Consensus Statement of the Harvard Hospitals. Burlington: Massachusetts Coalition for the Prevention of Medical Errors; 2006.
This consensus paper of the Harvard-affiliated hospitals was prepared by clinicians, risk managers, and patients to provide an in-depth understanding of preventable adverse events, their impact on patients, families, and providers, and how to manage such events. The report provides detailed guidelines based on the premise that all care should be safe and patient-centered and that all actions require full disclosure. In addition to offering recommendations on how to effectively communicate with patients and families, the report discusses support for caregivers and a detailed strategy for institutions to respond to such events in a timely and appropriate fashion. Finally, the comprehensive report offers several appendices that include recommendations and a case study on communicating with patients and families.
National Patient Safety Agency, the Medical Defence Union and Medical Protection Society. London, England: NPSA; 2005
This two-part report focuses on the experience of committing a medical error, along with strategies to reduce future events. The first part provides a series of shared stories from clinicians who discuss their personal experiences in making medical errors. The second part uses six case studies of errors as a background for expert analysis and discussion. The report also provides a motivation for reporting by explaining the benefits that come from such vigilance and how changing systems can lead to improved safety.
Bostock L, Bairstow S, Fish S, Macleod F. London, England: Social Care Institute for Excellence; 2005. ISBN: 1904812279.
This report suggests that a systems approach to child social services in Great Britain would facilitate a fair and open culture and encourage learning from near misses.
Bogner MS, ed. Mahwah, NJ: Lawrence Erlbaum Associates; 2004. ISBN: 0805833781.
External Inquiry into the adverse incident that occurred at Queen's Medical Centre, Nottingham, 4th January 2001.
Toft B. London, England: Department of Health; 2001.
This UK Department of Health report details a series of errors that led to the death of a young man due to wrong route administration of the chemotherapy drug vincristine. The fatality occurred as a result of a socio-technical systems failure at the hospital where he received the injection. The report makes 48 recommendations to help minimize the likelihood of this mistake.
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.