Review New perspectives on error in critical care. Citation Text: Patel VL, Cohen T. New perspectives on error in critical care. Curr Opin Crit Care. 2008;14(4):456-9. doi:10.1097/MCC.0b013e32830634ae. Copy Citation Format: DOIGoogle ScholarPubMedBibTeXEndNote X3 XMLEndNote 7 XMLEndnote taggedPubMedIdRIS Download Citation Save Save to your library Print Share Facebook Twitter Linkedin Copy URL September 17, 2008 Patel VL, Cohen T. Curr Opin Crit Care. 2008;14(4):456-9. View more articles from the same authors. This review article describes approaches to safety improvement that specifically address the complex nature of the clinical health care environment. PubMed citation Available at Save Save to your library Print Share Facebook Twitter Linkedin Copy URL Cite Citation Citation Text: Patel VL, Cohen T. New perspectives on error in critical care. Curr Opin Crit Care. 2008;14(4):456-9. doi:10.1097/MCC.0b013e32830634ae. Copy Citation Format: DOIGoogle ScholarPubMedBibTeXEndNote X3 XMLEndNote 7 XMLEndnote taggedPubMedIdRIS Download Citation Related Resources From the Same Author(s) Reevaluating recovery: perceived violations and preemptive interventions on emergency psychiatry rounds. March 21, 2007 Role of cognition in generating and mitigating clinical errors. May 20, 2015 A systematic review of the literature on the evaluation of handoff tools: implications for research and practice. June 26, 2013 Bridging gaps in handoffs: a continuity of care based approach. May 23, 2012 Error detection and recovery in dialysis nursing. November 30, 2011 Understanding pharmacist decision making for adverse drug event (ADE) detection. April 15, 2009 The nature and occurrence of registration errors in the emergency department. July 4, 2007 Interruptions in a level one trauma center: a case study. July 4, 2007 Comprehensive analysis of a medication dosing error related to CPOE. August 31, 2005 Clinical cognition and biomedical informatics: issues of patient safety. August 24, 2005 Attitudes toward medical device use errors and the prevention of adverse events. November 14, 2007 Decisions about critical events in device-related scenarios as a function of expertise. June 1, 2005 The multitasking clinician: decision-making and cognitive demand during and after team handoffs in emergency care. November 8, 2006 Implementation of the I-PASS handoff program in diverse clinical environments: a multicenter prospective effectiveness implementation study. November 16, 2022 The successful anesthesia patient safety officer. September 15, 2021 Families as partners in hospital error and adverse event surveillance. March 8, 2017 Patient safety after implementation of a coproduced family centered communication programme: multicenter before and after intervention study. December 19, 2018 Financial incentives to reduce hospital-acquired infections under alternative payment arrangements. March 28, 2018 Seroprevalence of SARS-CoV-2 among frontline health care personnel in a multistate hospital network--13 academic medical centers, April-June 2020. September 23, 2020 Clinical practice guideline: safe medication use in the ICU. August 30, 2017 Changes in medical errors after implementation of a handoff program. November 12, 2014 Assessing the state of safe medication practices using the ISMP Medication Safety Self Assessment for Hospitals: 2000 and 2011. February 5, 2014 The effect of clinician feedback interventions on opioid prescribing. April 27, 2022 ASHP guidelines on preventing medication errors with chemotherapy and biotherapy. April 22, 2015 Retained surgical items: a problem yet to be solved. October 31, 2012 Racial and ethnic differences in emergency department diagnostic imaging at US Children's Hospitals, 2016-2019. January 4, 2021 Strategies to reduce errors associated with 2-component vaccines. December 2, 2020 Understanding ultrarare adverse events - lessons learned from a twelve-year review of intraoperative deaths at an academic medical center. June 21, 2023 Medication safety event reporting: factors that contribute to safety events during times of organizational stress. May 24, 2023 Outbreak investigation of COVID-19 among residents and staff of an independent and assisted living community for older adults in Seattle, Washington. June 10, 2020 Perception of patient safety culture in pediatric long-term care settings. February 13, 2019 Association of the 2011 ACGME resident duty hour reform with general surgery patient outcomes and with resident examination performance. January 14, 2015 Underlying reasons associated with hospital readmission following surgery in the United States. February 18, 2015 The stories clinicians tell: achieving high reliability and improving patient safety. December 2, 2015 National cluster-randomized trial of duty-hour flexibility in surgical training. February 10, 2016 Association of the 2011 ACGME resident duty hour reform with postoperative patient outcomes in surgical specialties. August 12, 2015 ISMP medication error report analysis. March 10, 2010 Relationship between systems-level factors and hand hygiene adherence. June 9, 2010 ISMP medication error report analysis. May 12, 2010 CMS changes in reimbursement for HAIs: setting a research agenda. May 5, 2010 ISMP medication error report analysis. April 21, 2010 Shaping systems for better behavioral choices: lessons learned from a fatal medication error. March 24, 2010 The influence of resident involvement on surgical outcomes. January 30, 2005 Wrong-site craniotomy: analysis of 35 cases and systems for prevention. September 15, 2010 Using the ABCs of situational awareness for patient safety. June 5, 2013 Risk models to improve safety of dispensing high-alert medications in community pharmacies. November 7, 2012 Receipt of antibiotics in hospitalized patients and risk for Clostridium difficile infection in subsequent patients who occupy the same bed. October 19, 2016 Outcomes of concurrent operations: results from the American College of Surgeons' National Surgical Quality Improvement Program. October 11, 2017 Using the Assessment of Reasoning Tool to facilitate feedback about diagnostic reasoning. January 11, 2023 Is your code cart ready? September 28, 2005 Are language barriers associated with serious medical events in hospitalized pediatric patients? September 21, 2005 Unlabeled containers lead to patient's death. July 13, 2005 Medication safety program reduces adverse drug events in a community hospital. June 22, 2005 Patient reported receipt of medication instructions for warfarin is associated with reduced risk of serious bleeding events. October 1, 2008 Impact of computerized prescriber order entry on the incidence of adverse drug events in pediatric inpatients. November 21, 2007 Identifying and quantifying medication errors: evaluation of rapidly discontinued medication orders submitted to a computerized physician order entry system. May 21, 2008 National surveillance of emergency department visits for outpatient adverse drug events in children and adolescents. March 5, 2008 Role of computerized physician order entry systems in facilitating medication errors. April 3, 2005 Intimidation: practitioners speak up about this unresolved problem. October 5, 2005 Findings from the ISMP Medication Safety Self-Assessment for hospitals. March 6, 2005 Declaring uncertainty: using quality improvement methods to change the conversation of diagnosis. March 17, 2021 I-PASS Mentored Implementation Handoff Curriculum: implementation guide and resources. March 10, 2019 Association of provider specialty with abortion-related morbidity and adverse events among patients having procedural and medication abortions. August 10, 2022 Prevalence and causes of diagnostic errors in hospitalized patients under investigation for COVID-19. April 12, 2023 Preventability and causes of readmissions in a national cohort of general medicine patients. May 4, 2016 Evaluation of perioperative medication errors and adverse drug events. November 4, 2015 Randomized crossover study evaluating the effect of a hand sanitizer dispenser on the frequency of hand hygiene among anesthesiology staff in the operating room. July 2, 2014 What US hospitals are currently doing to prevent common device-associated infections: results from a national survey. May 8, 2019 I-PASS mentored implementation handoff curriculum: champion training materials. March 13, 2019 It is time to define antimicrobial never events. February 27, 2019 A human factors framework and study of the effect of nursing workload on patient safety and employee quality of working life. February 2, 2011 Resident participation does not affect surgical outcomes, despite introduction of new techniques. September 22, 2010 Quantifying and characterizing adverse events in dermatologic surgery. May 15, 2013 Self-reported violations during medication administration in two paediatric hospitals. May 16, 2012 The disruptive orthopaedic surgeon: implications for patient safety and malpractice liability. November 23, 2011 Nurses' communication of safety events to nursing home residents and families. November 15, 2017 Uncertain diagnoses in a children's hospital: patient characteristics and outcomes. April 1, 2020 Reduction in warfarin adverse events requiring patient hospitalization after implementation of a pharmacist-managed anticoagulation service. June 1, 2005 Prehospital naloxone and emergency department adverse events: a dose-dependent relationship. November 25, 2020 Rudeness and medical team performance. April 12, 2017 One size fits all? Mixed methods evaluation of the impact of 100% single-room accommodation on staff and patient experience, safety and costs. October 21, 2015 The impact of rudeness on medical team performance: a randomized trial. September 30, 2015 Is single room hospital accommodation associated with differences in healthcare-associated infection, falls, pressure ulcers or medication errors? A natural experiment with non-equivalent controls. February 17, 2016 Incivility and patient safety: a longitudinal study of rudeness, protocol compliance, and adverse events. April 10, 2019 Effectiveness of interventions designed to promote patient involvement to enhance safety: a systematic review. June 2, 2010 Human factors and error prevention in emergency medicine. June 15, 2011 A multicenter trial of aviation-style training for surgical teams. September 15, 2010 'Care left undone' during nursing shifts: associations with workload and perceived quality of care. August 14, 2013 Exploring physician perspectives of residency holdover handoffs: a qualitative study to understand an increasingly important type of handoff. August 2, 2017 International evaluation of an AI system for breast cancer screening. January 29, 2020 The contribution of staffing to medication administration errors: a text mining analysis of incident report data. December 18, 2019 The impact of health care strikes on patient mortality: a systematic review and meta-analysis of observational studies. November 30, 2022 Identifying risks areas related to medication administrations - text mining analysis using free-text descriptions of incident reports. February 12, 2020 The top 10 list for a safe and effective sign-out. November 5, 2008 Improving patient safety by identifying latent failures in successful operations. August 1, 2007 Clinical profile of hospitalized children provided with urgent assistance from a medical emergency team. June 18, 2008 Incidence, preventability and consequences of adverse events in older people: results of a retrospective case-note review. March 26, 2008 Extent, nature and consequences of adverse events: results of a retrospective casenote review in a large NHS hospital. December 12, 2007 Sensitivity of routine system for reporting patient safety incidents in an NHS hospital: retrospective patient case note review. January 3, 2007 Experience of wrong site surgery and surgical marking practices among clinicians in the UK. November 15, 2006 View More Related Resources Learning from non-routine events and teamwork in intensive care units: challenges and opportunities. February 28, 2024 Pediatric Diagnostic Safety: State of the Science and Future Directions. September 13, 2023 A scoping review of distributed cognition in acute care clinical decision-making. June 7, 2023 Patient Safety Innovations Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis May 31, 2023 Paediatric family activated rapid response interventions; qualitative systematic review. January 18, 2023 Family support role in hospital rapid response teams: a scoping review. April 13, 2022 Medication-related interventions to improve medication safety and patient outcomes on transition from adult intensive care settings: a systematic review and meta-analysis. February 2, 2022 Preventable medication harm across health care settings: a systematic review and meta-analysis. February 17, 2021 The effect of blue-enriched lighting on medical error rate in a university hospital ICU. January 27, 2021 Potential harm caused by physicians' a-priori beliefs in the clinical effectiveness of hydroxychloroquine and its impact on clinical and economic outcome--a simulation approach. January 20, 2021 Apparent cause analysis: a safety tool. May 20, 2020 Surviving Sepsis Campaign: international guidelines for management of sepsis and septic shock: 2016 March 3, 2017 Finding diagnostic errors in children admitted to the PICU. February 8, 2017 Performance of the Global Assessment of Pediatric Patient Safety (GAPPS) tool. June 15, 2016 Medical error—the third leading cause of death in the US. May 11, 2016 An observational study of adult admissions to a medical ICU due to adverse drug events. March 16, 2016 Epidemiology, patterns of care, and mortality for patients with acute respiratory distress syndrome in intensive care units in 50 countries. March 9, 2016 Aviation and healthcare: a comparative review with implications for patient safety. February 3, 2016 ICU attending handoff practices: results from a national survey of academic intensivists. December 9, 2015 Interorganizational complexity and organizational accident risk: a literature review. November 25, 2015 The effect of universal glove and gown use on adverse events in intensive care unit patients. September 30, 2015 Understanding medical errors and adverse events in ICU patients. September 16, 2015 An analysis of near misses identified by anesthesia providers in the intensive care unit. July 15, 2015 Improving clinical handover between intensive care unit and general ward professionals at intensive care unit discharge. March 18, 2015 A systematic review of adult admissions to ICUs related to adverse drug events. January 28, 2015 Application of the aviation black box principle in pediatric cardiac surgery: tracking all failures in the pediatric cardiac operating room. January 14, 2015 Measuring experiences and outcomes of patient safety in primary care: a systematic review of available instruments. October 29, 2014 Reducing medication errors in critical care: a multimodal approach. October 1, 2014 Preventable mortality after common urological surgery: failing to rescue? September 3, 2014 Racial and ethnic disparities in patient safety. August 27, 2014 View More See More About The Topic Intensive Care Units Quality and Safety Professionals Safety Scientists Critical Care Epidemiology of Errors and Adverse Events View More
Reevaluating recovery: perceived violations and preemptive interventions on emergency psychiatry rounds. March 21, 2007
A systematic review of the literature on the evaluation of handoff tools: implications for research and practice. June 26, 2013
The multitasking clinician: decision-making and cognitive demand during and after team handoffs in emergency care. November 8, 2006
Implementation of the I-PASS handoff program in diverse clinical environments: a multicenter prospective effectiveness implementation study. November 16, 2022
Patient safety after implementation of a coproduced family centered communication programme: multicenter before and after intervention study. December 19, 2018
Financial incentives to reduce hospital-acquired infections under alternative payment arrangements. March 28, 2018
Seroprevalence of SARS-CoV-2 among frontline health care personnel in a multistate hospital network--13 academic medical centers, April-June 2020. September 23, 2020
Assessing the state of safe medication practices using the ISMP Medication Safety Self Assessment for Hospitals: 2000 and 2011. February 5, 2014
Racial and ethnic differences in emergency department diagnostic imaging at US Children's Hospitals, 2016-2019. January 4, 2021
Understanding ultrarare adverse events - lessons learned from a twelve-year review of intraoperative deaths at an academic medical center. June 21, 2023
Medication safety event reporting: factors that contribute to safety events during times of organizational stress. May 24, 2023
Outbreak investigation of COVID-19 among residents and staff of an independent and assisted living community for older adults in Seattle, Washington. June 10, 2020
Association of the 2011 ACGME resident duty hour reform with general surgery patient outcomes and with resident examination performance. January 14, 2015
Underlying reasons associated with hospital readmission following surgery in the United States. February 18, 2015
The stories clinicians tell: achieving high reliability and improving patient safety. December 2, 2015
Association of the 2011 ACGME resident duty hour reform with postoperative patient outcomes in surgical specialties. August 12, 2015
Shaping systems for better behavioral choices: lessons learned from a fatal medication error. March 24, 2010
Risk models to improve safety of dispensing high-alert medications in community pharmacies. November 7, 2012
Receipt of antibiotics in hospitalized patients and risk for Clostridium difficile infection in subsequent patients who occupy the same bed. October 19, 2016
Outcomes of concurrent operations: results from the American College of Surgeons' National Surgical Quality Improvement Program. October 11, 2017
Using the Assessment of Reasoning Tool to facilitate feedback about diagnostic reasoning. January 11, 2023
Are language barriers associated with serious medical events in hospitalized pediatric patients? September 21, 2005
Patient reported receipt of medication instructions for warfarin is associated with reduced risk of serious bleeding events. October 1, 2008
Impact of computerized prescriber order entry on the incidence of adverse drug events in pediatric inpatients. November 21, 2007
Identifying and quantifying medication errors: evaluation of rapidly discontinued medication orders submitted to a computerized physician order entry system. May 21, 2008
National surveillance of emergency department visits for outpatient adverse drug events in children and adolescents. March 5, 2008
Declaring uncertainty: using quality improvement methods to change the conversation of diagnosis. March 17, 2021
I-PASS Mentored Implementation Handoff Curriculum: implementation guide and resources. March 10, 2019
Association of provider specialty with abortion-related morbidity and adverse events among patients having procedural and medication abortions. August 10, 2022
Prevalence and causes of diagnostic errors in hospitalized patients under investigation for COVID-19. April 12, 2023
Preventability and causes of readmissions in a national cohort of general medicine patients. May 4, 2016
Randomized crossover study evaluating the effect of a hand sanitizer dispenser on the frequency of hand hygiene among anesthesiology staff in the operating room. July 2, 2014
What US hospitals are currently doing to prevent common device-associated infections: results from a national survey. May 8, 2019
A human factors framework and study of the effect of nursing workload on patient safety and employee quality of working life. February 2, 2011
Resident participation does not affect surgical outcomes, despite introduction of new techniques. September 22, 2010
The disruptive orthopaedic surgeon: implications for patient safety and malpractice liability. November 23, 2011
Reduction in warfarin adverse events requiring patient hospitalization after implementation of a pharmacist-managed anticoagulation service. June 1, 2005
Prehospital naloxone and emergency department adverse events: a dose-dependent relationship. November 25, 2020
One size fits all? Mixed methods evaluation of the impact of 100% single-room accommodation on staff and patient experience, safety and costs. October 21, 2015
Is single room hospital accommodation associated with differences in healthcare-associated infection, falls, pressure ulcers or medication errors? A natural experiment with non-equivalent controls. February 17, 2016
Incivility and patient safety: a longitudinal study of rudeness, protocol compliance, and adverse events. April 10, 2019
Effectiveness of interventions designed to promote patient involvement to enhance safety: a systematic review. June 2, 2010
'Care left undone' during nursing shifts: associations with workload and perceived quality of care. August 14, 2013
Exploring physician perspectives of residency holdover handoffs: a qualitative study to understand an increasingly important type of handoff. August 2, 2017
The contribution of staffing to medication administration errors: a text mining analysis of incident report data. December 18, 2019
The impact of health care strikes on patient mortality: a systematic review and meta-analysis of observational studies. November 30, 2022
Identifying risks areas related to medication administrations - text mining analysis using free-text descriptions of incident reports. February 12, 2020
Clinical profile of hospitalized children provided with urgent assistance from a medical emergency team. June 18, 2008
Incidence, preventability and consequences of adverse events in older people: results of a retrospective case-note review. March 26, 2008
Extent, nature and consequences of adverse events: results of a retrospective casenote review in a large NHS hospital. December 12, 2007
Sensitivity of routine system for reporting patient safety incidents in an NHS hospital: retrospective patient case note review. January 3, 2007
Experience of wrong site surgery and surgical marking practices among clinicians in the UK. November 15, 2006
Learning from non-routine events and teamwork in intensive care units: challenges and opportunities. February 28, 2024
Patient Safety Innovations Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis May 31, 2023
Paediatric family activated rapid response interventions; qualitative systematic review. January 18, 2023
Medication-related interventions to improve medication safety and patient outcomes on transition from adult intensive care settings: a systematic review and meta-analysis. February 2, 2022
Preventable medication harm across health care settings: a systematic review and meta-analysis. February 17, 2021
The effect of blue-enriched lighting on medical error rate in a university hospital ICU. January 27, 2021
Potential harm caused by physicians' a-priori beliefs in the clinical effectiveness of hydroxychloroquine and its impact on clinical and economic outcome--a simulation approach. January 20, 2021
Surviving Sepsis Campaign: international guidelines for management of sepsis and septic shock: 2016 March 3, 2017
An observational study of adult admissions to a medical ICU due to adverse drug events. March 16, 2016
Epidemiology, patterns of care, and mortality for patients with acute respiratory distress syndrome in intensive care units in 50 countries. March 9, 2016
ICU attending handoff practices: results from a national survey of academic intensivists. December 9, 2015
Interorganizational complexity and organizational accident risk: a literature review. November 25, 2015
The effect of universal glove and gown use on adverse events in intensive care unit patients. September 30, 2015
An analysis of near misses identified by anesthesia providers in the intensive care unit. July 15, 2015
Improving clinical handover between intensive care unit and general ward professionals at intensive care unit discharge. March 18, 2015
Application of the aviation black box principle in pediatric cardiac surgery: tracking all failures in the pediatric cardiac operating room. January 14, 2015
Measuring experiences and outcomes of patient safety in primary care: a systematic review of available instruments. October 29, 2014