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Search results for ""
Cook RI, Woods DD. In: Bogner MS, ed. Human Error in Medicine. Hillsdale, NJ: Erlbaum and Associates; 1994:255-310.
The authors provide an introduction to systems failure and human error. They discuss these issues in light of how they affect large complex systems. Many of the examples are from anesthesiology, but the conclusions can be applied broadly throughout health care.
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.
Wolf ZR. Albany, NY: Delmar Publishing, Inc; 1994.
In one of the first professional books to deal with medication error from the nursing perspective, Wolf provides a comprehensive introduction to medication error for the nursing community, both students and seasoned practitioners alike. Topics covered include a student's experience with error, individual response to making a mistake, and the value of storytelling. The author provides solutions for dealing with error once it happens. The book closes with a teaching plan to help educate nurses about error reduction and a review of factors that contribute to medical mistakes in the nursing corps.
Gerteis M, Edgman-Levitan S, Daley J, Delbanco TL, eds. San Francisco, CA: Jossey-Bass; 1993. ISBN 9781555425449.
Authored by several leaders of the Picker/Commonwealth Program for Patient-Centered Care, this book demonstrates the broad impact of the program. The authors discuss the key tenets of patient-centered care, drawing on empirical research, theory, and results of many surveys of patients, providers, and administrators. The authors provide many practical suggestions, a number of which have been adopted since the book's first publication in 1993. Examples include giving patients access to their medical records, giving them ''written and/or visual information identifying members of the clinical team," and offering ''culturally sensitive educational materials tailored to specific ethnic groups.''
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.
Sagan SD. Princeton, NJ: Princeton University Press; 1993.
Two competing paradigms dominate the study of the hazards associated with complex organizations. The more optimistic of these paradigms, high-reliability theory, focuses on organizations that have achieved exemplary safety records and identifies key factors contributing to these records, including a high priority for safety within the organization, significant levels of redundancy, decentralization of authority, and organizational learning. Normal accident theory takes a more pessimistic view by asserting that, with a certain degree of complexity and when processes are time dependent and tightly coupled, major accidents become almost inevitable. In fact, redundancy, decentralized decision making, and many specific safety measures may only increase the degree to which actions in one part of the system can produce unexpected, baffling effects in other parts of the system. Sagan sets out to test these two competing theories by answering the question: why has there never been an accidental nuclear war? The results of Sagan's detailed archival research initially appear to confirm the predictions of high-reliability theory. However, interviews with key personnel uncover several hair-raising near misses during the Cuban missile crisis. In fact, Sagan ultimately concludes that good fortune played a greater role than good design in the safety record of the nuclear weapons industry to date.
Senders JW, Morey NP. Hillsdale, NJ: Lawrence Erlbaum; 1991.
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.
Kahneman D, Slovic P, Tversky A, eds. Cambridge, England: Cambridge University Press; 1982. ISBN-13: 9780521284141.
The Definition of Quality and Approaches to Its Assessment. Vol 1. Explorations in Quality Assessment and Monitoring.
Donabedian A. Ann Arbor, MI: Health Administration Press; 1980.
Quality and safety are ultimately determined by the degree to which health care improves important patient outcomes. However, documenting variations in morbidity and mortality is labor intensive. In this first volume, Donabedian develops the framework for measuring quality by assessing elements of structure or process with proven connections to key outcomes of interest. This framework may seem straightforward now, but only because Donabedian's approach has become the paradigm for quality measurement in health care. Despite the wide dissemination of the structure-process-outcome triad, Donabedian's original work remains worth reading. Those who wish to sample a briefer introduction can look at a review article by Donabedian in the Journal of the American Medical Association (The quality of care: how can it be assessed? JAMA. 1988;260:1743-1748).
Elstein AS. Boston, MA: Harvard University Press; 1978.
Clinical reasoning lies at the heart of formulating diagnoses and selecting treatments. The results of these medical decisions determine a substantial portion of the dollars spent on health care. Considering the fundamental importance of clinical reasoning, the topic has received surprisingly little systematic study. Even with the widespread interest in medical error and patient safety in recent years, diagnostic errors and other errors in clinical reasoning have received little attention. This classic collection of empiric studies on clinical reasoning in action thus remains highly relevant more than 25 years after its original publication. One finding of particular relevance for those interested in patient safety and quality improvement is that competence may be problem specific; thus, there is no generic approach to clinical problem solving that, when followed, ensures excellent, or even competent, performance in a variety of domains within a field. The authors also provide an excellent overview of theoretic models relevant to the study of clinical reasoning.
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.)