Citizendium - building a quality free general knowledge encyclopedia. Click here to join and contribute—free
Many thanks December donors; special to Darren Duncan. January donations open; need minimum total $100. Let's exceed that.

Donate here. By donating you gift yourself and CZ.


Medical error

From Citizendium, the Citizens' Compendium

Jump to: navigation, search
This article is developing and not approved.
Main Article
Talk
Related Articles  [?]
Bibliography  [?]
External Links  [?]
Citable Version  [?]
 
This editable Main Article is under development and not meant to be cited; by editing it you can help to improve it towards a future approved, citable version. These unapproved articles are subject to a disclaimer.

Contents

Medical errors are mistakes that are made in a medical setting. Errors are made by every type of health care worker, and in every hospital and health care facility. In 2001, the U.S. Institute of Medicine estimated that, every year, 44,000–98,000 deaths in the USA were related to medical errors. [1]

Errors are not limited to medical workers and may include any decision maker involved in medical care, including the patient themselves. For example, reimbursements by medical insurance may be poorly structured resulting in less than optimal outcomes.[2]

When an error occurs, the key question becomes, will it be recognized and corrected? Errors that eventually result in injury are typically compounded by subsequent errors of not recognizing that an error has occurred, and not taking remedial action.

Epidemiology/frequency

Errors may occur among hospitalized patients, ambulatory patients, or patients after discharge from the hospital.[3]

The frequency of errors is higher when physicians and patients are asked about their experience with errors among their families.[4]

The frequency of meaningful medical error is debated.[5]

Most patients in intensive care experience at least one error.[6]

Reporting requirements

In the United States reporting medical errors in hospitals is a condition of payment by Medicare.[7] An investigation by the Office of Inspector General, Department of Health and Human Services released January 6, 2012 found that most errors are not reported and even in the case of errors that are reported and investigated changes are seldom made which would prevent them in the future. The investigation revealed that there was often lack of knowledge regarding which events were reportable and recommended that lists of reportable events be developed. [8]

Classification

Errors can be classified into "no fault," "system-related", and "cognitive".[9]

No fault

Examples including overlooking a disease that in a patient with manifestations so atypical that most doctors would not be expected to recognize the underlying disease.

System-related

Examples of system errors include "problems with policies and procedures, inefficient processes, teamwork, and communication."[9] Errors may happen during transfer of care.[10] In medical training, breakdowns in teamwork (including supervision) are a cause[11][12], especially at the beginning of the academic year[13][14].

Interruptions have a complicated affect on error and cognition.[15]

Unclear instructions to health personnel

Unclear prose, whether in institutional instructions[16] or reports[17][18], may contribute to errors.

Ill-defined clinical flow processes

The results of abnormal diagnostic tests may not acted upon.[19][20]

Work load

Examining errors in administration of parenteral medications in intensive care, a study found:[21]

  • 74 errors per 100 patient-days
  • Independent risk factors were:
    • Patient complexity as measured by
      • number of organ failures
      • number of parenteral administrations
    • Work load as measured by
      • Larger intensive care unit
      • Increased ratio of patient turnover to the size of the unit
      • Number of patients per nurse
      • Occupancy rate of the unit

Workload may also be associated with adverse outcomes in emergency rooms.[22]

On the other hand, insufficient volume of care is associated with reduced quality of care.[23]

Inadequate staffing

Many studies show that adverse events are associated with low staffing.[24][25][26]

Weekends and off hours

Inadequate provision of medical care for patients admitted on weekends may increase adverse outcomes in most[27][28][29][30][31][32] but not all[33] studies. The same may be true for in-hospital cardiac arrest.[32] "The weekend effect was larger in major teaching hospitals compared with nonteaching hospitals."[30]

The reduced quality of care during off hours may improve as a hospital has more experience in quality improvement.[34]

Failure to rescue

Hospitals have similar incidence of surgical complications, yet varying incidence of nosocomial death. This suggests that some hospitals have a "failure to rescue" patients from complications.[35]

Hospital discharge

For more information, see: Patient discharge.


Cognitive

Voytovich has suggested that diagnostic error due to cognitive errors can be further classified into omission of finding, premature closure, inadequate synthesis, and wrong formulation.[36] Similarly, Graber has classified cognitive error into faulty knowledge, faulty data gathering, and faulty synthesis (usually premature closure).[9] An additional classification has been proposed by Kassirer.[37] In medical trainees, cognitive errors are an important cause or medical error.[11] The many cognitive biases that can lead to cognitive error have been inventoried.[38][39]

Omission of finding

An example is recording a finding during data collection, but not including the finding on the problem list.[36]

Faulty data gathering

An example of faulty data gathering is and incomplete physical examination or not ordering needed tests.[9]

Premature closure

Premature closure is the most common cognitive error.[9][36]

Wrong formulation

Examples of wrong formulation or flawed reasoning are making a diagnosis that is contradicted by clinical findings.

Inadequate knowledge

Inadequate knowledge can be a factor[40], but is uncommon as an isolated problem in studies of causes of medical errors.[9] However, inadequate knowledge was found to be a more common problem in study of appropriateness of care among patients without identified medical errors.[41] It is unclear how often each of the types of cognitive errors such as an incomplete evaluation, omission of a finding, wrong formulation, are partly due to inadequate knowledge of diseases.

System-related cognitive deficits

At the interface between system-related errors and cognitive errors, one finds the errors that are learnt in the course of the formative years, in medical schools.

Needless to say, doctors are expected to have a very high degree of moral development: the profession requires an ability to make choices that will impact on the quality of life of innumerable patients, and to act appropriately and diligently when faced with life-or-death situations. Doctors are expected to master an enormous amount of knowledge, and to advance beyond when faced with the grey areas of clinical practice.

It is recognized that higher education has a favourable impact on moral development: university students tend to reason more in societal and principled terms when faced with ethical issues, and less in terms of self-interest or peer approval, the more they advance in their university curriculum. The medical curriculum is a notable exception to this rule.

It is now recognized that medical education, as it is today, hinders moral development.[42][43][44]The reason why medical education forms doctors that will be less able to take ethical decisions than other professionals with comparable levels of education is still not known with certainty, although the so-called "hidden curriculum"[45] appears to be a likely culprit.[46]

Patient related

Patients who have more medical problems[47] and more complaints[48] may have reduced quality of care due to competing demands on physician time.

Malpractice

For more information, see: Medical malpractice.

If an error involves negligence and results in damage, as those terms are legally defined, it may be treated as medical malpractice and result in substantial liability. The possibility of legal liability can be a barrier to free discussion and disclosure of medical error, hampering efforts to reduce error. Thus, provisions for confidential reporting of errors can be useful.

Prevention

Lessons from aviation

Plane crashes can be dramatic events, causing considerable loss of life and attracting wide publicity damaging to the reputation of the airlines involved, and weakening passenger confidence in air travel. Accordingly, all plane crashes and related serious incidents ("near misses") are exhaustively investigated in an effort to establish their precise causes. By comparison, most medical errors do not have the same wide impact, thus they seldom receive such intense scrutiny and analysis. [49]

An adapted version of a "pilot's checklist" (designed to ensure that safety procedures are rigorously followed when preparing for take-off and landing) has been tested for usefulness in preparation for performing Cesarean delivery under general anesthesia. [50]

Another aviation safety method, with potential healthcare benefit, is crew resource management (CRM), also called cockpit resource management. While the captain of an aircraft is the ultimate authority, CRM helps ensure that all crew members are proactive in sharing safety-related information. [51] Some of CRM principles include peer monitoring, acceptance that team members do make errors, and that each team member has responsibility both for the patient and for situational awareness. The method cannot be transferred directly to medicine, but has potential to be modified to medicine.

Some of the differences include that cockpit crew are usually all certified pilots with differing levels of experience in the same basic skill set, while healthcare teams involve people not only with different levels of experience, but different skills and lack of skills. A surgeon may not have the physiologic intuition of an anesthesiologist, but the surgeon is the authority. An experienced surgical nurse may see a young surgeon about to make an error, but a concept of nurse vs. physician roles may reduce the chance of a warning being issued, or perhaps being accepted.

Aviators also have one motivator that is far less common than in medicine: shared fate. While a break in barrier methods may infect a healthcare team member, the implications are not as drastic as the failure of a copilot to assert the aircraft did not have adequate takeoff speed, which should have caused the takeoff to be aborted, rather than Air Florida 93 crashing into the 14th Street Bridge in Washington DC.

Hospital design

See also: electronic medical record, electronic health record, clinical decision support system, and medical order entry system.

Patients placed in isolation rooms for infection control "experience more preventable adverse events, express greater dissatisfaction with their treatment, and have less documented care."[52]

Bar coding medication administration may reduce errors.[53]

Personnel factors

Sleep deprivation

Sleep deprivation may contribute to errors.[54]

Reduction of duty hours

See also Medical education

A survey of 200 residents who trained both before and after duty hours reform reported improved quality of life. However, "Residents reported that whereas fatigue-related errors decreased slightly, errors related to reduced continuity of care significantly increased." [55] Resident believe excessive work hours is a common cause of medical error.[56][57][58]

Restricting duty hours may[59][60][61] or may not[62] improve performance. However, restrictions may be costly.[63]

Oversight of professional conduct

It is not clear that the oversight of professional conduct prevents errors.

Organizations promoting error reduction

Institute for Healthcare Improvement

The Institute for Healthcare Improvement (IHI) defines medical harm as "unintended physical injury resulting from or contributed to by medical care (including the absence of indicated medical treatment) that requires additional monitoring, treatment or hospitalization, or results in death."

100,000 Lives Campaign

In 2004, the IHI initiated the 100,000 Lives Campaign.[64][65] That campaign, participated in by 3,200 hospitals, is estimated to have reduced deaths of patients in hospitals by 122,000 in 18 months. The campaign focused on six "interventions", three focused on common hospital-acquired (nosocomial infections), which had been identified as likely to reduce medical error:

  1. "Deploy Rapid Response Teams…at the first sign of patient decline". Rapid Response Teams (RRSs) are teams of critical care experts. Use of Rapid Response Teams has increased dramatically in U.S. Hospitals, from near zero in 2003 to 1500 in 2006. [66] RRSs have been helpful in some[67], but not all studies.[68][69]
  2. "Deliver Reliable, Evidence-Based Care for Acute Myocardial Infarction…to prevent deaths from heart attack."
  3. "Prevent Adverse Drug Events (ADEs)…by implementing medication reconciliation."[70][71]
  4. "Prevent Central Line Infections…by implementing a series of interdependent, scientifically grounded steps called the "Central Line Bundle"."
  5. "Prevent Surgical Site Infections…by reliably delivering the correct perioperative antibiotics at the proper time." Significant reduction may be achieved by procedures as simple as proper hand washing, use of clippers rather than razors to shave the site of surgery, or prompt administration of antibiotics following surgery.[66][72]
  6. "Prevent Ventilator-Associated Pneumonia…by implementing a series of interdependent, scientifically grounded steps including the 'Ventilator Bundle'."
5 Million Lives Campaign

IHI's second campaign, the 5 Million Lives Campaign, [73] aims to eliminate five million incidents of medical harm during a 24-month period, ending Dec. 9, 2008. The campaign challenges 4,000 hospitals to adopt at least one of twelve interventions: the six original interventions and the following six more: [74] [75]

  1. "Prevent Harm from High-Alert Medications... starting with a focus on anticoagulants, sedatives, narcotics, and insulin."
  2. "Reduce Surgical Complications... by reliably implementing all of the changes in care recommended by SCIP, the Surgical Care Improvement Project (http://www.medqic.org/scip)."
  3. "Prevent Pressure Ulcers... by reliably using science-based guidelines for their prevention."
  4. "Reduce Methicillin-Resistant Staphylococcus aureus (MRSA) infection…by reliably implementing scientifically proven infection control practices."
  5. "Deliver Reliable, Evidence-Based Care for Congestive Heart Failure... to avoid readmissions."
  6. "Get Boards on Board … by defining and spreading the best-known leveraged processes for hospital Boards of Directors, so that they can become far more effective in accelerating organizational progress toward safe care."

Agency for Healthcare Research Quality

The American Agency for Healthcare Research and Quality has established 11 priority areas:[76]

  1. Appropriate use of prophylaxis to prevent venous thromboembolism in patients at risk.
  2. Use of perioperative beta-blockers in appropriate patients to prevent perioperative morbidity and mortality.
  3. Use of maximum sterile barriers while placing central intravenous catheters to prevent infections.
  4. Appropriate use of antibiotic prophylaxis in surgical patients to prevent perioperative infections.
  5. Asking that patients recall and restate what they have been told during the informed consent process.
  6. Continuous aspiration of subglottic secretions (CASS) to prevent ventilator-associated pneumonia.
  7. Use of pressure relieving bedding materials to prevent pressure ulcers.
  8. Use of real-time ultrasound guidance during central line insertion to prevent complications.
  9. Patient self-management for warfarin (CoumadinTM) to achieve appropriate outpatient anticoagulation and prevent complications.
  10. Appropriate provision of nutrition, with a particular emphasis on early enteral nutrition in critically ill and surgical patients.
  11. Use of antibiotic-impregnated central venous catheters to prevent catheter-related infections.

Joint Commission

The Joint Commission promotes a number of goals that are listed at http://www.jcrinc.com/National-Patient-Safety-Goals/.

United States Surgeon General

The United States Surgeon General has announced calls to action to improve medical care in the following areas:

  • Prevent Deep Vein Thrombosis and Pulmonary Embolism
  • Prevent and Reduce Underage Drinking
  • The Surgeon General’s Call to Action to Improve the Health and Wellness of Persons with Disabilities
  • National Call To Action To Promote Oral Health
  • Prevent and Decrease Overweight and Obesity
  • Promote Sexual Health and Responsible Sexual Behavior
  • Prevent Suicide

The Patient Advocate

Reduction of medical error can be effected on the patient side as well as on the side of the care giver, but only with vigilance on the part of the patient him or herself, or on the part of the patient's advocate.

Payment

Generally medical treatment to correct medical error has been considered billable, but effective October 1, 2008 Medicare will discontinue paying hospitals for treatment resulting from 10 common medical errors. Other insurance carriers are expected to follow suit.[77][78][79] In addition to 7 other conditions, the errors which not will be paid for include three "never events": objects left in the body during surgery, air embolisms and blood incompatibility.[80]

Serious Reportable Events

The full list of "never events", serious reportable events, was developed by the National Quality Forum (NQF) in 2002, and refined in 2006. It includes the following:

Surgical Events

  • Surgery performed on the wrong body part
  • Surgery performed on the wrong patient
  • Wrong surgical procedure performed on a patient
  • Unintended retention of a foreign object in a patient after surgery or other procedure
  • Intraoperative or immediately postoperative death in an ASA Class I patient

Product of Device Events

  • Patient death or serious disability associated with the use of contaminated drugs, devices or biologics provided by the healthcare facility
  • Patient death or serious disability associated with the use or function of a device in patient care in which the device is used or functions other than as intended
  • Patient death or serious disability associated with intravascular air embolism that occurs while being cared for in a healthcare facility

Patient Protection Events

  • Infant discharged to the wrong person
  • Patient death or serious disability associated with patient leaving the facility without permission
  • Patient suicide, or attempted suicide, resulting in serious disability while being cared for in a healthcare facility

Care Management Events

  • Patient death or serious disability associated with a medication error (e.g. errors involving the wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation or wrong route of administration)
  • Patient death or serious disability associated with a hemolytic reaction (abnormal breakdown of red blood cells) due to the administration of ABO/HLA – incompatible blood or blood products
  • Maternal death or serious disability associated with labor or delivery in a low-risk pregnancy while being cared for in a healthcare facility
  • Patient death or serious disability associated with hypoglycemia, the onset of which occurs while the patient is being cared for in a healthcare facility
  • Death or serious disability associated with failure to identify and treat hyperbilirubinemia (condition where there is a high amount of bilirubin in the blood) in newborns
  • Stage 3 or 4 pressure ulcers acquired after admission to a healthcare facility
  • Patient death or serious disability due to spinal manipulative therapy
  • Artificial insemination with the wrong donor sperm or wrong egg

Environmental Events

  • Patient death or serious disability associated with an electric shock while being cared for in a healthcare facility
  • Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains the wrong gas or is contaminated by toxic substances
  • Patient death or serious disability associated with a burn incurred from any source while being cared for in a healthcare facility
  • Patient death or serious disability associated with a fall while being cared for in a healthcare facility
  • Patient death or serious disability associated with the use of restraints or bedrails while being cared for in a healthcare facility

Criminal Events

  • Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed healthcare provider
  • Abduction of a patient of any age
  • Sexual assault on a patient within or on the grounds of a healthcare facility
  • Death or significant injury of a patient or staff member resulting form a physical assault (i.e., battery) that occurs within or on the grounds of a healthcare facility[81]

The physician's perspective

Medical case reports review the strongly negative emotional impact of mistakes on the doctors who allegedly commit them.[82][83][84][85][86]

Coping mechanisms

Essays[87] and studies[88][89] have described physician coping mechanisms.

Mistakes are not isolated events

Some doctors recognize that adverse outcomes from errors usually do not happen because of an isolated errors and actually reflect system problems.[90] There may be several breakdowns in processes to allow one adverse outcome. [91] In addition, competing demands[92][93] on the provider's attention can reduce quality of care[47][94]. However, placing too much blame on the system may not be constructive.[90]

Medicine in perspective

Essayists imply that the potential to make mistakes is part of what makes being a physician rewarding and without this potential the rewards of medical practice would be less:

  • "Everybody dies, you and all of your patients. All relationships end. Would you want it any other way?...Don't take it personally"[95]
  • "... if I left medicine, I would mourn its loss as I've mourned the passage of my poetry. On a daily basis, it is both a privilege and a joy to have the trust of patients and their families and the camaraderie of peers. There is no challenge to make your blood race like that of a difficult case, no mind game as rigorous as the challenging differential diagnosis, and though the stakes are high, so are the rewards."[96]

Disclosing mistakes

Forgiveness, which is a part of many religions, may be important in coping with medical mistakes.[97]

To oneself

Inability to forgive oneself may create a cycle of distress and increased likelihood of a future error.[98]

However, "...those who coped by accepting responsibility were more likely to make constructive changes in practice, but to experience more emotional distress."[99] It may be helpful to consider the much larger number of patients who are not exposed to mistakes and are helped by medical care.[96]

To patients

Patients are reported to want "information about what happened, why the error happened, how the error's consequences will be mitigated, and how recurrences will be prevented."[100] Detailed suggestions on how to disclose are available.[101]

The American Medical Association's Council on Ethical and Judicial Affairs states in its ethics code:

"Situations occasionally occur in which a patient suffers significant medical complications that may have resulted from the physician's mistake or judgment. In these situations, the physician is ethically required to inform the patient of all facts necessary to ensure understanding of what has occurred. Concern regarding legal liability which might result following truthful disclosure should not affect the physician's honesty with a patient."

From the American College of Physicians Ethics Manual[102]:

“In addition, physicians should disclose to patients information about procedural or judgment errors made in the course of care if such information is material to the patient's well-being. Errors do not necessarily constitute improper, negligent, or unethical behavior, but failure to disclose them may.”

However, "there appears to be a gap between physicians' attitudes and practices regarding error disclosure. Willingness to disclose errors was associated with higher training level and a variety of patient-centered attitudes, and it was not lessened by previous exposure to malpractice litigation".[103] Hospital administrators may share these concerns.[104]

Consequently, in the United States, many states have enacted laws excluding expressions of sympathy after accidents as proof of liability; however, "excluding from admissibility in court proceedings apologetic expressions of sympathy but not fault-admitting apologies after accidents"[105]

Disclosure may actually reduce malpractice payments.[106][107]

To non-physicians

In a study of physicians who reported having made a mistake, disclosing to non-physicians sources of support may reduce stress more than disclosing to physician colleagues[89]. This may be due to the physicians in the same study, when presented with a hypothetical scenario of a mistake made by another colleague, only 32% physicians would have unconditionally offered support. It is possible that greater benefit occurs when spouses are physicians[108].

To other physicians

Discussing mistakes with other doctors is beneficial.[90] However, doctors may be less forgiving of each other.[108] The reason is not clear, but one essayist has admonished, "Don't Take Too Much Joy in the Mistakes of Other Doctors."[109]

Disclosure to the physician's institution

Disclosure of errors, especially 'near misses' may be able to reduce subsequent errors in institutions that are capable of reviewing near misses.[110] However, doctors report that institutions may not be supportive of the doctor.[90]

See also

References

  1. Page 1, To Err Is Human: Building a Safer Health System, Janet Corrigan, Molla S. Donaldson, and Linda T. Kohn, editors, National Academy Press (April, 2000), 287 pages, ISBN 0309-06837-1
  2. "Hospitals Pay for Cutting Costly Readmissions" article by Reed Abelson in The New York Times May 8, 2009
  3. Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW (2003). "The incidence and severity of adverse events affecting patients after discharge from the hospital". Ann. Intern. Med. 138 (3): 161–7. PMID 12558354[e]
  4. Blendon RJ, DesRoches CM, Brodie M, Benson JM, Rosen AB, Schneider E et al. (2002). "Views of practicing physicians and the public on medical errors.". N Engl J Med 347 (24): 1933-40. DOI:10.1056/NEJMsa022151. PMID 12477944. Research Blogging.
  5. Hayward RA, Hofer TP (2001). "Estimating hospital deaths due to medical errors: preventability is in the eye of the reviewer". JAMA 286 (4): 415–20. PMID 11466119[e]
  6. Garrouste-Orgeas M, Timsit JF, Vesin A, Schwebel C, Arnodo P, Lefrant JY et al. (2010). "Selected medical errors in the intensive care unit: results of the IATROREF study: parts I and II.". Am J Respir Crit Care Med 181 (2): 134-42. DOI:10.1164/rccm.200812-1820OC. PMID 19875690. Research Blogging.
  7. "Report Finds Most Errors at Hospitals Go Unreported" article by Robert Pear in The New York Times January 6, 2012
  8. Summary "Hospital Incident Reporting Systems Do Not Capture Most Patient Harm" Report (OEI-06-09-00091) Office of Inspector General, Department of Health and Human Services, January 6, 2012
  9. 9.0 9.1 9.2 9.3 9.4 9.5 Graber ML, Franklin N, Gordon R (2005). "Diagnostic error in internal medicine". Arch. Intern. Med. 165 (13): 1493–9. DOI:10.1001/archinte.165.13.1493. PMID 16009864. Research Blogging.
  10. Horwitz LI et al. (2008) Dropping the Baton: A Qualitative Analysis of Failures During the Transition From Emergency Department to Inpatient Care. Annals of Emergency MedicineDOI:10.1016/j.annemergmed.2008.05.007
  11. 11.0 11.1 Singh H, Thomas EJ, Petersen LA, Studdert DM (2007). "Medical errors involving trainees: a study of closed malpractice claims from 5 insurers". Arch. Intern. Med. 167 (19): 2030–6. DOI:10.1001/archinte.167.19.2030. PMID 17954795. Research Blogging.
  12. Horwitz LI, Moin T, Krumholz HM, Wang L, Bradley EH (September 2008). "Consequences of Inadequate Sign-out for Patient Care". Arch. Intern. Med. 168 (16): 1755–60. DOI:10.1001/archinte.168.16.1755. PMID 18779462. Research Blogging.
  13. Inaba K, Recinos G, Teixeira PG, Barmparas G, Talving P, Salim A et al. (2010). "Complications and death at the start of the new academic year: is there a July phenomenon?". J Trauma 68 (1): 19-22. DOI:10.1097/TA.0b013e3181b88dfe. PMID 20065752. Research Blogging.
  14. Haller G, Myles PS, Taffé P, Perneger TV, Wu CL (2009). "Rate of undesirable events at beginning of academic year: retrospective cohort study.". BMJ 339: b3974. DOI:10.1136/bmj.b3974. PMID 19826176. Research Blogging.
  15. Li SY, Magrabi F, Coiera E (2011). "A systematic review of the psychological literature on interruption and its patient safety implications.". J Am Med Inform Assoc. DOI:10.1136/amiajnl-2010-000024. PMID 21946236. Research Blogging.
  16. Wheeler DW, Carter JJ, Murray LJ, et al (2008). "The effect of drug concentration expression on epinephrine dosing errors: a randomized trial". Ann. Intern. Med. 148 (1): 11–4. PMID 18166759[e]
  17. Bundens WP, Bergan JJ, Halasz NA, Murray J, Drehobl M (1995). "The superficial femoral vein. A potentially lethal misnomer". JAMA 274 (16): 1296–8. PMID 7563535[e]
  18. Pritchard J, Foley P, Wong H (2003). "Langerhans and Langhans: what's misleading in a name?". Lancet 362 (9387): 922. DOI:1016/S0140-6736(03)14323-1. PMID 13678997. Research Blogging.
  19. Callen JL, Westbrook JI, Georgiou A, Li J (2011). "Failure to Follow-Up Test Results for Ambulatory Patients: A Systematic Review.". J Gen Intern Med. DOI:10.1007/s11606-011-1949-5. PMID 22183961. Research Blogging.
  20. Davis Giardina T, Singh H (2011). "Should patients get direct access to their laboratory test results? An answer with many questions.". JAMA 306 (22): 2502-3. DOI:10.1001/jama.2011.1797. PMID 22122864. Research Blogging.
  21. Valentin A, Capuzzo M, Guidet B, et al (2009). "Errors in administration of parenteral drugs in intensive care units: multinational prospective study". BMJ 338: b814. PMID 19282436[e]
  22. Arora, Sanjeev; Karla Thornton, Glen Murata, Paulina Deming, Summers Kalishman, Denise Dion, Brooke Parish, Thomas Burke, Wesley Pak, Jeffrey Dunkelberg, Martin Kistin, John Brown, Steven Jenkusky, Miriam Komaromy, Clifford Qualls (2011-06). "Outcomes of Treatment for Hepatitis C Virus Infection by Primary Care Providers". New England Journal of Medicine: 110601140030042. DOI:10.1056/NEJMoa1009370. ISSN 0028-4793. Retrieved on 2011-06-02. Research Blogging.
  23. Kumbhani DJ, Cannon CP, Fonarow GC, Liang L, Askari AT, Peacock WF et al. (2009). "Association of hospital primary angioplasty volume in ST-segment elevation myocardial infarction with quality and outcomes.". JAMA 302 (20): 2207-13. DOI:10.1001/jama.2009.1715. PMID 19934421. Research Blogging.
  24. Liu JM, Yang Q, Pirrallo RG, Klein JP, Aufderheide TP (2008). "Hospital variability of out-of-hospital cardiac arrest survival". Prehosp Emerg Care 12 (3): 339–46. DOI:10.1080/10903120802101330. PMID 18584502. Research Blogging.
  25. Amaravadi RK, Dimick JB, Pronovost PJ, Lipsett PA (December 2000). "ICU nurse-to-patient ratio is associated with complications and resource use after esophagectomy". Intensive Care Med 26 (12): 1857–62. PMID 11271096[e]
  26. Cho SH, Ketefian S, Barkauskas VH, Smith DG (2003). "The effects of nurse staffing on adverse events, morbidity, mortality, and medical costs". Nurs Res 52 (2): 71–9. PMID 12657982[e]
  27. Bendavid E, Kaganova Y, Needleman J, Gruenberg L, Weissman JS (May 2007). "Complication rates on weekends and weekdays in US hospitals". Am. J. Med. 120 (5): 422–8. DOI:10.1016/j.amjmed.2006.05.067. PMID 17466653. Research Blogging.
  28. Magid DJ, Wang Y, Herrin J, et al (August 2005). "Relationship between time of day, day of week, timeliness of reperfusion, and in-hospital mortality for patients with acute ST-segment elevation myocardial infarction". JAMA 294 (7): 803–12. DOI:10.1001/jama.294.7.803. PMID 16106005. Research Blogging.
  29. Kostis WJ, Demissie K, Marcella SW, Shao YH, Wilson AC, Moreyra AE (2007). "Weekend versus weekday admission and mortality from myocardial infarction". N. Engl. J. Med. 356 (11): 1099–109. DOI:10.1056/NEJMoa063355. PMID 17360988. Research Blogging.
  30. 30.0 30.1 Cram P, Hillis SL, Barnett M, Rosenthal GE (2004). "Effects of weekend admission and hospital teaching status on in-hospital mortality". Am. J. Med. 117 (3): 151–7. DOI:10.1016/j.amjmed.2004.02.035. PMID 15276592. Research Blogging.
  31. Bell CM, Redelmeier DA (2001). "Mortality among patients admitted to hospitals on weekends as compared with weekdays". N. Engl. J. Med. 345 (9): 663–8. PMID 11547721[e]
  32. 32.0 32.1 Peberdy MA, Ornato JP, Larkin GL, et al (February 2008). "Survival from in-hospital cardiac arrest during nights and weekends". JAMA : the journal of the American Medical Association 299 (7): 785–92. DOI:10.1001/jama.299.7.785. PMID 18285590. Research Blogging.
  33. Gould JB, Qin C, Marks AR, Chavez G (2003). "Neonatal mortality in weekend vs weekday births". JAMA 289 (22): 2958–62. DOI:10.1001/jama.289.22.2958. PMID 12799403. Research Blogging.
  34. Reeves, Mathew J; Eric Smith, Gregg Fonarow, Adrian Hernandez, Wenqin Pan, Lee H Schwamm (2009-02). "Off-hour admission and in-hospital stroke case fatality in the get with the guidelines-stroke program". Stroke; a Journal of Cerebral Circulation 40 (2): 569-576. DOI:10.1161/STROKEAHA.108.519355. ISSN 1524-4628. PMID 18988914. Retrieved on 2009-09-01. Research Blogging.
  35. Ghaferi AA, Birkmeyer JD, Dimick JB (2009). "Variation in hospital mortality associated with inpatient surgery.". N Engl J Med 361 (14): 1368-75. DOI:10.1056/NEJMsa0903048. PMID 19797283. Research Blogging.
  36. 36.0 36.1 36.2 Dubeau CE, Voytovich AE, Rippey RM (1986). "Premature conclusions in the diagnosis of iron-deficiency anemia: cause and effect". Medical decision making : an international journal of the Society for Medical Decision Making 6 (3): 169–73. PMID 3736379[e]
  37. Kassirer JP, Kopelman RI (1989). "Cognitive errors in diagnosis: instantiation, classification, and consequences". Am. J. Med. 86 (4): 433–41. PMID 2648823[e]
  38. Croskerry P (2002). "Achieving quality in clinical decision making: cognitive strategies and detection of bias". Academic emergency medicine : official journal of the Society for Academic Emergency Medicine 9 (11): 1184–204. PMID 12414468[e]
  39. Ely JW, Kaldjian LC, D'Alessandro DM (2012). "Diagnostic errors in primary care: lessons learned.". J Am Board Fam Med 25 (1): 87-97. DOI:10.3122/jabfm.2012.01.110174. PMID 22218629. Research Blogging.
  40. Graber M, Gordon R, Franklin N (2002). "Reducing diagnostic errors in medicine: what's the goal?". Academic medicine : journal of the Association of American Medical Colleges 77 (10): 981–92. PMID 12377672[e]
  41. Lucas BP, Evans AT, Reilly BM, et al (2004). "The impact of evidence on physicians' inpatient treatment decisions". Journal of general internal medicine : official journal of the Society for Research and Education in Primary Care Internal Medicine 19 (5 Pt 1): 402–9. DOI:10.1111/j.1525-1497.2004.30306.x. PMID 15109337. Research Blogging.
  42. Crandall SJ, Volk RJ, Loemker V (May 1993). "Medical students' attitudes toward providing care for the underserved. Are we training socially responsible physicians?". JAMA 269 (19): 2519–23. PMID 8487415[e] In this study, only male medical students were found to be handicapped in their moral reasoning.
  43. Osborn E (March 2000). "Punishment: a story for medical educators". Acad Med 75 (3): 241–4. PMID 10724311[e] This analysis focuses on the enforcement by medical schools of a logic of factual accuracy to the detriment of creative thinking.
  44. Hébert PC, Meslin EM, Dunn EV (September 1992). "Measuring the ethical sensitivity of medical students: a study at the University of Toronto". J Med Ethics 18 (3): 142–7. PMID 1404281. PMC 1376259[e] Ethical sensitivity and moral reasoning ability are two distinct endpoints. This study deals with the former only.
  45. The "hidden curriculum" is the whole set of attitudes and mindsets that are promoted implicitely by teachers. The importance of the hidden curriculum was eloquently expressed by Dr Albert Schweitzer: "Example is not the main thing in influencing others. It's the only thing".
  46. Patenaude J, Niyonsenga T, Fafard D (April 2003). "Changes in students' moral development during medical school: a cohort study". CMAJ 168 (7): 840–4. PMID 12668541. PMC 151989[e]
  47. 47.0 47.1 Redelmeier DA, Tan SH, Booth GL (1998). "The treatment of unrelated disorders in patients with chronic medical diseases.". N Engl J Med 338 (21): 1516-20. PMID 9593791.
  48. Parchman ML, Pugh JA, Romero RL, Bowers KW (2007 May-Jun). "Competing demands or clinical inertia: the case of elevated glycosylated hemoglobin.". Ann Fam Med 5 (3): 196-201. DOI:10.1370/afm.679. PMID 17548846. PMC PMC1886492. Research Blogging.
  49. Robert L Helmreich RL (2000) On error management: lessons from aviation. BMJ320:781-5
  50. Hart EM, Owen H (2005) Errors and omissions in anesthesia: a pilot study using a pilot's checklist. Anesthesia & Analgesia 101:246-50 PMID 15976240
  51. Pizzi, Laura; Neil I. Goldfarb & David B. Nash (July 2001), Chapter 44. Crew Resource Management and its Applications in Medicine, Making Health Care Safer: A Critical Analysis of Patient Safety Practices, Agency for Healthcare Research and Quality, Evidence Report/Technology Assessment, No. 43
  52. Stelfox HT, Bates DW, Redelmeier DA (2003). "Safety of patients isolated for infection control". JAMA 290 (14): 1899–905. DOI:10.1001/jama.290.14.1899. PMID 14532319. Research Blogging.
  53. Poon, Eric G.; Carol A. Keohane, Catherine S. Yoon, Matthew Ditmore, Anne Bane, Osnat Levtzion-Korach, Thomas Moniz, Jeffrey M. Rothschild, Allen B. Kachalia, Judy Hayes, William W. Churchill, Stuart Lipsitz, Anthony D. Whittemore, David W. Bates, Tejal K. Gandhi (2010-05-06). "Effect of Bar-Code Technology on the Safety of Medication Administration". N Engl J Med 362 (18): 1698-1707. DOI:10.1056/NEJMsa0907115. Retrieved on 2010-05-06. Research Blogging.
  54. Rothschild JM, Keohane CA, Rogers S, Gardner R, Lipsitz SR, Salzberg CA et al. (2009). "Risks of complications by attending physicians after performing nighttime procedures.". JAMA 302 (14): 1565-72. DOI:10.1001/jama.2009.1423. PMID 19826026. Research Blogging.
  55. Myers JS et al. (2006)Internal medicine and general surgery residents' attitudes about the ACGME duty hours regulations: a multicenter study, Academic Medicine 81:1052-8, PMID 17122468
  56. Jagsi R, Kitch BT, Weinstein DF, Campbell EG, Hutter M, Weissman JS (2005). "Residents report on adverse events and their causes". Arch. Intern. Med. 165 (22): 2607–13. DOI:10.1001/archinte.165.22.2607. PMID 16344418. Research Blogging.
  57. Vidyarthi AR, Auerbach AD, Wachter RM, Katz PP (February 2007). "The impact of duty hours on resident self reports of errors". J Gen Intern Med 22 (2): 205–9. DOI:10.1007/s11606-006-0065-4. PMID 17356987. PMC 1824755. Research Blogging.
  58. Barger LK, Ayas NT, Cade BE, et al (December 2006). "Impact of extended-duration shifts on medical errors, adverse events, and attentional failures". PLoS Med. 3 (12): e487. DOI:10.1371/journal.pmed.0030487. PMID 17194188. PMC 1705824. Research Blogging.
  59. Bhavsar J, Montgomery D, Li J, et al (November 2007). "Impact of duty hours restrictions on quality of care and clinical outcomes". Am. J. Med. 120 (11): 968–74. DOI:10.1016/j.amjmed.2007.07.026. PMID 17976424. Research Blogging.
  60. Shetty KD, Bhattacharya J (July 2007). "Changes in hospital mortality associated with residency work-hour regulations". Ann. Intern. Med. 147 (2): 73–80. PMID 17548403[e]
  61. Volpp KG, Rosen AK, Rosenbaum PR, et al (September 2007). "Mortality among patients in VA hospitals in the first 2 years following ACGME resident duty hour reform". JAMA 298 (9): 984–92. DOI:10.1001/jama.298.9.984. PMID 17785643. Research Blogging.
  62. Volpp KG, Rosen AK, Rosenbaum PR, et al (September 2007). "Mortality among hospitalized Medicare beneficiaries in the first 2 years following ACGME resident duty hour reform". JAMA 298 (9): 975–83. DOI:10.1001/jama.298.9.975. PMID 17785642. Research Blogging.
  63. Nuckols TK, Bhattacharya J, Wolman DM, Ulmer C, Escarce JJ (May 2009). "Cost implications of reduced work hours and workloads for resident physicians". N. Engl. J. Med. 360 (21): 2202–15. DOI:10.1056/NEJMsa0810251. PMID 19458365. Research Blogging.
  64. Berwick DM, Calkins DR, McCannon CJ, Hackbarth AD (2006). "The 100,000 lives campaign: setting a goal and a deadline for improving health care quality". JAMA 295 (3): 324–7. DOI:10.1001/jama.295.3.324. PMID 16418469. Research Blogging.
  65. Institute for Healthcare Improvement: Overview of the 100,000 Lives Campaign. Retrieved on 2008-01-03.
  66. 66.0 66.1 “Status Quon’t”, IHI’s 2007 Progress Report (PDF file)
  67. Lighthall GK, Parast LM, Rapoport L, Wagner TH (2010). "Introduction of a rapid response system at a United States veterans affairs hospital reduced cardiac arrests.". Anesth Analg 111 (3): 679-86. DOI:10.1213/ANE.0b013e3181e9c3f3. PMID 20624835. Research Blogging.
  68. Ranji SR, Auerbach AD, Hurd CJ, O'Rourke K, Shojania KG (2007). "Effects of rapid response systems on clinical outcomes: systematic review and meta-analysis". J Hosp Med 2 (6): 422–32. DOI:10.1002/jhm.238. PMID 18081187. Research Blogging.
  69. Chan PS, Jain R, Nallmothu BK, Berg RA, Sasson C (2010). "Rapid Response Teams: A Systematic Review and Meta-analysis.". Arch Intern Med 170 (1): 18-26. DOI:10.1001/archinternmed.2009.424. PMID 20065195. Research Blogging.
  70. Schnipper JL, Hamann C, Ndumele CD, et al. (April 2009). "Effect of an electronic medication reconciliation application and process redesign on potential adverse drug events: a cluster-randomized trial". Arch. Intern. Med. 169 (8): 771–80. DOI:10.1001/archinternmed.2009.51. PMID 19398689. Research Blogging.
  71. Jack BW, Chetty VK, Anthony D, et al. (February 2009). "A reengineered hospital discharge program to decrease rehospitalization: a randomized trial". Ann. Intern. Med. 150 (3): 178–87. PMID 19189907[e]
  72. "Nosocomial Infection: Approach to Postoperative Symptoms of Infection", From ACS Surgery Online, Posted 06/07/2006, E. Patchen Dellinger, M.D., F.A.C.S.
  73. Institute for Healthcare Improvement: Campaign. Retrieved on 2008-01-03.
  74. "Overview of the 5 Million Lives Campaign"
  75. "IHI Launches National Initiative to Reduce Medical Harm in U.S. Hospitals, Builds on 100,000 Lives Campaign" Infection Control Today, December 12, 2006
  76. Clear Opportunities for Safety Improvement. Agency for Healthcare Research Quality (2001). Retrieved on 2008-02-12.
  77. Pear, Robert. Medicare Says It Won’t Cover Hospital Errors, The New York Times, 2007-08-18. Retrieved on 2008-10-01.
  78. Sack, Kevin. Medicare Won’t Pay for Medical Errors, The New York Times, 2008-09-30. Retrieved on 2008-10-01.
  79. Preventable conditions, The New York Times, 2008-09-30. Retrieved on 2008-10-01.
  80. Medicare, Kaiser Daily Health Policy Report, 2008-10-01. Retrieved on 2008-10-01.
  81. Fact Sheet Serious Reportable Events
  82. Hilfiker D (1984). "Facing our mistakes". N. Engl. J. Med. 310 (2): 118-22. PMID 6690918[e]
  83. Christensen JF, Levinson W, Dunn PM (1992). "The heart of darkness: the impact of perceived mistakes on physicians". Journal of general internal medicine : official journal of the Society for Research and Education in Primary Care Internal Medicine 7 (4): 424-31. PMID 1506949[e]
  84. Wu AW (2000). "Medical error: the second victim. The doctor who makes the mistake needs help too". BMJ 320 (7237): 726-7. PMID 10720336[e]
  85. Waterman AD, Garbutt J, Hazel E, Dunagan WC, Levinson W, Fraser VJ, Gallagher TH. (2007). "The Emotional Impact of Medical Errors on Practicing Physicians in the United States and Canada". Joint Commission Journal on Quality and Patient Safety 33: 467-476. PMID 6690918[e]
  86. Delbanco T, Bell SK (2007). "Guilty, afraid, and alone--struggling with medical error". N. Engl. J. Med. 357 (17): 1682–3. DOI:10.1056/NEJMp078104. PMID 17960011. Research Blogging.
  87. Oscar London (1987). “Rule 13: When You Make a Mistake So Horrible It is to Die Over, Don't”, Kill as few patients as possible: and fifty-six other essays on how to be the world's best doctor. Berkeley, Calif: Ten Speed Press, 23-24. ISBN 0-89815-197-X. 
  88. Quill TE, Williamson PR. Healthy approaches to physician stress. Arch Intern Med. 1990;150:1857-61. PMID 2393317
  89. 89.0 89.1 Newman MC (1996). "The emotional impact of mistakes on family physicians". Archives of family medicine 5 (2): 71-5. PMID 8601210[e]
  90. 90.0 90.1 90.2 90.3 Wu AW, Folkman S, McPhee SJ, Lo B (1991). "Do house officers learn from their mistakes?". JAMA 265 (16): 2089-94. PMID 2013929[e]
  91. Gandhi TK, Kachalia A, Thomas EJ, et al (2006). "Missed and delayed diagnoses in the ambulatory setting: a study of closed malpractice claims". Ann. Intern. Med. 145 (7): 488-96. PMID 17015866[e]
  92. Lurie N, Rank B, Parenti C, Woolley T, Snoke W (1989). "How do house officers spend their nights? A time study of internal medicine house staff on call". N. Engl. J. Med. 320 (25): 1673-7. PMID 2725617[e]
  93. Lyle CB, Applegate WB, Citron DS, Williams OD (1976). "Practice habits in a group of eight internists". Ann. Intern. Med. 84 (5): 594-601. PMID 1275366[e]
  94. Bolen SD, Samuels TA, Yeh HC, et al (May 2008). "Failure to intensify antihypertensive treatment by primary care providers: a cohort study in adults with diabetes mellitus and hypertension". J Gen Intern Med 23 (5): 543–50. DOI:10.1007/s11606-008-0507-2. PMID 18219539. Research Blogging.
  95. Thomas Laurence, (2004). “What Do You Want?”, Extreme Clinic -- An Outpatient Doctor's Guide to the Perfect 7 Minute Visit. Philadelphia: Hanley & Belfus, 120. ISBN 1-56053-603-9. 
  96. 96.0 96.1 Seder D (2006). "Of poems and patients". Ann. Intern. Med. 144 (2): 142. PMID 16418416[e]
  97. Berlinger N, Wu A (2005). "Subtracting insult from injury: addressing cultural expectations in the disclosure of medical error". J Med Ethics 31 (2): 106-8. PMID 15681676.
  98. West CP, Huschka MM, Novotny PJ, et al (2006). "Association of perceived medical errors with resident distress and empathy: a prospective longitudinal study". JAMA 296 (9): 1071-8. DOI:10.1001/jama.296.9.1071. PMID 16954486. Research Blogging.
  99. Wu AW, Folkman S, McPhee SJ, Lo B (1993). "How house officers cope with their mistakes". West. J. Med. 159 (5): 565-9. PMID 8279153[e]
  100. Gallagher TH, Waterman AD, Ebers AG, Fraser VJ, Levinson W (2003). "Patients' and physicians' attitudes regarding the disclosure of medical errors". JAMA 289 (8): 1001-7. PMID 12597752[e]
  101. Wu AW, Cavanaugh TA, McPhee SJ, Lo B, Micco GP (1997). "To tell the truth: ethical and practical issues in disclosing medical mistakes to patients". Journal of general internal medicine : official journal of the Society for Research and Education in Primary Care Internal Medicine 12 (12): 770-5. DOI:10.1046/j.1525-1497.1997.07163.x. PMID 9436897. Research Blogging.
  102. Snyder L, Leffler C (2005). "Ethics manual: fifth edition". Ann Intern Med 142 (7): 560-82. PMID 15809467.
  103. Kaldjian LC, Jones EW, Wu BJ, Forman-Hoffman VL, Levi BH, Rosenthal GE (2007). "Disclosing medical errors to patients: attitudes and practices of physicians and trainees". Journal of general internal medicine : official journal of the Society for Research and Education in Primary Care Internal Medicine 22 (7): 988-96. DOI:10.1007/s11606-007-0227-z. PMID 17473944. Research Blogging.
  104. Weissman JS, Annas CL, Epstein AM, et al (2005). "Error reporting and disclosure systems: views from hospital leaders". JAMA 293 (11): 1359-66. DOI:10.1001/jama.293.11.1359. PMID 15769969. Research Blogging.
  105. SorryWorks.net. Retrieved on 2007-08-16.
  106. Wu AW (1999). "Handling hospital errors: is disclosure the best defense?". Ann. Intern. Med. 131 (12): 970-2. PMID 10610651[e]
  107. Zimmerman R. Doctors' New Tool To Fight Lawsuits: Saying 'I'm Sorry', Dow Jones & Company, Inc, May 18,2004. Retrieved on 2007-08-16.
  108. 108.0 108.1 Sobecks NW, Justice AC, Hinze S, et al (1999). "When doctors marry doctors: a survey exploring the professional and family lives of young physicians". Ann. Intern. Med. 130 (4 Pt 1): 312-9. PMID 10068390[e]
  109. Oscar London (1987). “Rule 35: Don't Take Too Much Joy in the Mistakes of Other Doctors”, Kill as few patients as possible: and fifty-six other essays on how to be the world's best doctor. Berkeley, Calif: Ten Speed Press. ISBN 0-89815-197-X. 
  110. Barach P, Small SD (2000). "Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems". BMJ 320 (7237): 759-63. PMID 10720361[e]
Views
Personal tools