| Medical
College of Wisconsin Physicians & Clinics |
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American
Academy of Family Physicians |
| 20
Tips to Help Prevent Medical Errors |
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Disclosing
the Truth About a Medical Error |
| Medical
errors are one of the Nation's leading causes of death and injury.
A 1999 report by the Institute of Medicine estimates that as
many as 44,000 to 98,000 people die in US hospitals each year
as the result of medical errors. This means that more people
die from medical errors than from >> |
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As
soon as my patient told me she was having heavy, prolonged menstrual
periods and fatigue, I realized my mistake. Two months earlier,
I had checked her thyroid-stimulating hormone (TSH) level to
monitor her response to the treatment of hyperthyroidism. She
had been doing well >>
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| Visual
Expert |
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BMJ
2000 |
| Error
and Injury in Computers & Medical Devices |
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Error
in medicine |
| Computers
are playing an increasing role in everyday life, so it is not
surprising that incidents involving computers have become a
common matter of litigation. In a wide variety of technical,
financial and other situations, people make decisions and
>>
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The
consensus this week is that medicine lags behind other industries
that are safety critical. The principal remedy will be to change
from a culture of blame to a learning culture, in which the
focus of inquiry shifts from the individual to the system in
which errors >> |
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| Web
Journal of Current Issues |
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Risk
Management Foundation |
| Errors,
Medicine and the Law |
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FDA
and Medication Error |
| Errors,
Medicine and the Law is a most timely contribution to the enduring
debate about how society should respond to accidents in general,
and medical accidents in particular. It is a work that challenges
us to rethink >> |
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In
recent years, efforts at the national level to prevent medication
errors have included collaborative quality improvement projects
and the establishment of a National Patient Safety Foundation
at the AMA. Last month >> |
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| Medical
Error Reduction |
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Visual
Expert |
| Consumer |
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Human
Error in Medicine |
| Medical
error and patient safety issues and the concerns of consumers
of healthcare services is the focus of this page. >> |
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First
things first: "medical error" is not "medicine"
it is "error." The discipline appropriate to its study
and diagnosis is not medicine >> |
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| BMJ
2002 |
|
AARP |
| How
the US news media made patient safety a priority |
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Medical
Error and Patient Injury: Costly and Often Preventable |
| Until
journalists "remembered" patient safety, it was an
issue that society and the profession had largely forgotten.
Studies began to appear regularly in the medical literature
after the second world war. Two of the most comprehensive, those
of >> |
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Patient
injuries that result from preventable medical errors are widespread
and costly.1 One recent study found that more than one in six
hospitalized patients suffered medical injuries that prolonged
their hospital stays.2 It has been estimated that total annual
>>
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| Medical
Error Reduction |
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Medical
Error Reduction |
| How
Not To Share Bad News |
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A
Visit To The Dentist |
| The
following situation took place at a well-respected teaching
hospital on the West Coast of the United States. Family members
wait in a very comfortable room with chairs, couches, a TV and
beautiful artwork on the wall. Some people pace and some just
sit. >> |
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Yesterday
I took my three children to their Orthodontist for a check-up
on the progress of improving their smiles. The scheduled times
were in the afternoon following school. Matt(16) and Mike(14)
are towards the end of treatment while Kristen(12) is >> |
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| Glasgow
Accident Analysis Group |
|
New
England Journal of Medicine |
Identification
and Analysis of Incidents in Complex, Medical Environments
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Incidence
of adverse events and negligence in hospitalized patients |
| Medical
risk management is often seen as lagging behind other safety-critical
industries, where there has been considerable research into
safety and accident causation models. Accident analysis models
used in, for instance, aviation and process >> |
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As
part of an interdisciplinary study of medical injury and malpractice
litigation, we estimated the incidence of adverse events, defined
as injuries caused by medical management, and of the subgroup
of such injuries that resulted from negligent or substandard
care. >> |
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| Books |
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Links |
| Medical
error and patient safety books in the world today number in
the hundreds of books. At this web page we focus on major books
on the topics of healthcare error and patient safety. We also
include classic quality improvement >> |
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Medical
error and patient safety internet web links allow people to
learn about the work of improvement in healthcare throughout
the world. At MedicalErrorReduction.com we include sites with
a specific error reduction or quality >> |
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| Bandolier
Library |
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AHRQ |
| Computer
systems prevent errors |
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Medical
Error-prevention Strategies Face Barriers to Acceptance |
| What
is the evidence that giving healthcare professionals better
tools makes them perform the complicated tasks they do better?
A systematic review of computer based clinical decision >> |
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Strategies
to reduce the incidence of medical errors frequently point to
the positive role that technology, such as bar-coded medications,
hand-held wireless devices, and computer drug order-entry systems,
>> |
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| AHRQ |
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Medical
Students JAMA |
| Medical
Errors & Patient Safety |
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Medical
Students and Remediation of Error |
The
very critical issues of medical errors and patient safety have
received a great deal of attention. In November 1999, the Institute
of Medicine (IOM) released a report estimating that as many
as 98,000 patients die as the result of medical errors in hospitals
each year. >>
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The
landscape of medicine is strewn with lapses of judgment and
slips of the knife and pen that mar the orderly lines of scientific
practice. The Harvard Medical Practice study found that errors
resulting in adverse events occurred in approximately 10% of
patients. >> |
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| Public
Health |
|
Risk
Management Foundation |
|
Morbidity
and mortality from medical errors
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New
Approach to Medical Error |
| From
1983 to 1998, U.S. fatalities from acknowledged prescription
errors increased by 243%, from 2,876 to 9,856. This percentage
increase was greater than for almost any other cause of death,
and far outpaced the increase in the number of prescriptions.
>>
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A
professor of psychiatry at Harvard Medical School, Dr. Miles
Shore is a member of an exclusive group of health care industry
leaders that began meeting in January. He says that their mission
is nothing less than to develop a new paradigm for reducing
medical error >> |
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| Bridge |
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AHRQ |
| New
Technology Aids in Reduction of Hospital Medication Errors and
Supports CQI Initiatives |
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Reporting
Requirements Cloud Consensus on Curbing Medical Errors |
| The
Institute of Medicine recently stated that more than 7,000 Americans
die each year as a result of medication errors in hospitals.
This year at HIMSS 2000, Bridge Medical is >> |
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How
to reduce the occurrence of medical errors and serious mistakes
that jeopardize a patient's life or well-being has moved from
the anonymity of hospital safety review committees to the spotlight
of >> |
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| RCGP |
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American
Medical News |
| Setting
up a database of medical error in general practice |
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State
legislatures tackle medical error reporting |
| Following
Department of Health (DH) proposals, earlier this year, to set
up a national system for mandatory reporting of all adverse
health care incidents, a discussion paper in next month's issue
of the British Journal of >> |
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More
than a year after the Institute of Medicine issued its scathing
report on medical errors, state legislatures across the country
are still grappling with ways to address the issue. Eight new
laws were passed in 2000 in the report's >>
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| BMJ
2000 |
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American
Journal of Law & Medicine |
| Error
in medicine |
|
Medical
error as false claim |
| The
consensus this week is that medicine lags behind other industries
that are safety critical. The principal remedy will be to change
from a culture of blame to a learning culture, in which the
focus of inquiry shifts from >> |
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Medical
error and health care fraud are hot topics these days. Since
the Fall 1999 publication of the Institute of Medicine ("IOM")
Report, To Err is Human, medical errors have received a great
deal of attention in the popular and academic press. >> |
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| QSHC |
|
BMJ |
QHC
to become QSHC ... |
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Detecting
and reporting medical errors: why the dilemma? |
| One
fundamental guarantee that we cannot give our patients is that
faults and errors in the healthcare system won't harm them.
Of course, health care is by its nature risky. Not everyone
undergoing surgery for an aortic aneurysm survives. >> |
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Errors
in medicine are a major cause of harm to patients. Though there
is little controversy among clinicians about the importance
of accurate and reliable clinical data and the imperative of
correct diagnosis, that commitment to exactitude dissolves >> |
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| CMAI |
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BMJ |
| Disclosure
of medical error |
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Epidemiology
of medical error |
| A
37-year-old woman with an unremarkable medical history visits
her physician for a physical examination. As the physician is
about to enter the examining room, she is taken aside >> |
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Newspaper
and television stories of catastrophic injuries occurring at
the hands of clinicians spotlight the problem of medical error
but provide little insight into its nature or magnitude. >> |
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| BMJ |
|
BMJ |
| Error,
stress, and teamwork in medicine and aviation |
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How
to investigate and analyse clinical incidents |
| To
survey operating theatre and intensive care unit staff about
attitudes concerning error, stress, and teamwork and to compare
these attitudes with those of airline cockpit crew. >> |
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Why
do things go wrong? Human error is routinely blamed for disasters
in the air, on the railways, in complex surgery, and in health
care generally. However, quick judgments and routine >> |
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| BMJ |
|
JAMA |
| On
error management: lessons from aviation |
|
Promoting
Patient Safety
by Preventing Medical Error |
| Pilots
and doctors operate in complex environments where teams interact
with technology. In both domains, risk varies from low to high
with threats coming from a variety of sources >> |
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In
1995, a series of highly publicized medical incidents with serious
adverse patient consequences awakened public and professional
interest in safety in health care. In response to this >> |
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| BMJ |
|
Quality
Health Care |
| Reducing
error, improving safety |
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The
need for risk management to evolve to assure aculture of safety |
| It
was brave to devote a whole issue to medical error - how to
recognise, how to investigate, how to analyse, and how to change
systems to improve >> |
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There
is a need for the traditional risk management model, which focuses
on department based risk assessment, loss management and risk
financing, >> |
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|
| American
College of Physicians |
|
BMJ |
| The
Wrong Patient |
|
Human
error: models and management |
| Among
all types of medical errors, cases in which the wrong patient
undergoes an invasive procedure are sufficiently distressing
to warrant special attention. >> |
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The
human error problem can be viewed in two ways: the person approach
and the system approach. Each has its model of error causation
and each model gives >> |
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| National
health policy forum |
|
West
J Med |
| Improving
Quality and Preventing Error in Medical Practice |
|
Let's
talk about error |
| Front
pages of major newspapers and lead stories of network newscasts
had a startling common message just after Thanksgiving: medical
mistakes are killing people! The genesis of the outcry was >> |
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In
the time it will take you to read this editorial, eight patients
will be injured, and one will die, because of preventable medical
errors. Medication error - wrong drug, wrong dose, wrong
route of >> |
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| BMJ |
|
CMAJ |
| Medical
errors |
|
Medical
error and patient safety |
| In
his editorial on medical errors Alberti mentions studies of
adverse events from Australia and the United States. He then
welcomes a paper by Vincent >> |
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After
years of "the culture of silence," medical error and
patient safety have become topics for open discussion. Public
expectations of greater transparency >> |
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| BMJ |
|
BMJ |
| Medical
errors: a common problem |
|
Medical
errors and medical culture |
| Medical
errors continue to dominate newspaper headlines. There
is rarely an informed comment on likelihood or cause, rather
a tacit assumption >> |
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A
junior doctor fails to read an electrocardiogram that has been
ordered and the patient dies,
undiagnosed and in pain, from a myocardial infarction. >> |
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| American
College of Physicians |
|
Health
Care Journalists |
| Medical
malpractice |
|
A brief
history of the patient safety movement |
| To
examine the causal effects of doctor-patient relations and the
severity of a medical outcome on medical patient perceptions
and malpractice intentions >> |
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A
case came before the Supreme Court, involving a female epileptic
who sued her surgeon for removing her uterus and ovaries without
telling her his intentions in advance. >> |
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| BMJ |
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The
Scottish Parliament |
| A
system of medical error disclosure |
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The
Macfarlane trust & no-fault compensation
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| External
mandates for medical error disclosure are often justified by
potential cost savings, the belief in individual moral obligations
in health care, and the concept >> |
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This
Note sets out the particulars of the Macfarlane Trust for those
infected with HIV from contaminated blood. It also sets out
the particulars of no-fault systems >> |
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| American
College of Physicians |
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Why
it matters: The medical system is a leading killer
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| In
1998, reporters Fred Schulte and Jenni Bergal at the Fort Lauderdale
Sun-Sentinel wanted to find deaths from cosmetic surgery, but
their reporting had hit a dead end. >> |
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