Learning From Medical Errors

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To Err Is Human

Author : Institute of Medicine,Committee on Quality of Health Care in America
Publisher : National Academies Press
Page : 312 pages
File Size : 47,8 Mb
Release : 2000-03-01
Category : Medical
ISBN : 9780309068376

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To Err Is Human by Institute of Medicine,Committee on Quality of Health Care in America Pdf

Experts estimate that as many as 98,000 people die in any given year from medical errors that occur in hospitals. That's more than die from motor vehicle accidents, breast cancer, or AIDSâ€"three causes that receive far more public attention. Indeed, more people die annually from medication errors than from workplace injuries. Add the financial cost to the human tragedy, and medical error easily rises to the top ranks of urgent, widespread public problems. To Err Is Human breaks the silence that has surrounded medical errors and their consequenceâ€"but not by pointing fingers at caring health care professionals who make honest mistakes. After all, to err is human. Instead, this book sets forth a national agendaâ€"with state and local implicationsâ€"for reducing medical errors and improving patient safety through the design of a safer health system. This volume reveals the often startling statistics of medical error and the disparity between the incidence of error and public perception of it, given many patients' expectations that the medical profession always performs perfectly. A careful examination is made of how the surrounding forces of legislation, regulation, and market activity influence the quality of care provided by health care organizations and then looks at their handling of medical mistakes. Using a detailed case study, the book reviews the current understanding of why these mistakes happen. A key theme is that legitimate liability concerns discourage reporting of errorsâ€"which begs the question, "How can we learn from our mistakes?" Balancing regulatory versus market-based initiatives and public versus private efforts, the Institute of Medicine presents wide-ranging recommendations for improving patient safety, in the areas of leadership, improved data collection and analysis, and development of effective systems at the level of direct patient care. To Err Is Human asserts that the problem is not bad people in health careâ€"it is that good people are working in bad systems that need to be made safer. Comprehensive and straightforward, this book offers a clear prescription for raising the level of patient safety in American health care. It also explains how patients themselves can influence the quality of care that they receive once they check into the hospital. This book will be vitally important to federal, state, and local health policy makers and regulators, health professional licensing officials, hospital administrators, medical educators and students, health caregivers, health journalists, patient advocatesâ€"as well as patients themselves. First in a series of publications from the Quality of Health Care in America, a project initiated by the Institute of Medicine

Learning from Medical Errors

Author : Anh Vu Nguyen,Dung Nguyen
Publisher : CRC Press
Page : 54 pages
File Size : 43,9 Mb
Release : 2018-10-08
Category : Medical
ISBN : 9781315358314

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Learning from Medical Errors by Anh Vu Nguyen,Dung Nguyen Pdf

As medical litigation continues to increase, the best defence for doctors is to be aware of, and avoid, medical errors. This book focuses on the key legal issues including medical documentation, which reduce risk and liability when handled correctly. It contains chapters on difficult patients and special issues for emergency physicians. The case-based format demonstrates clinical relevance and useful examples are drawn from office, hospital and community settings. This book is the companion volume to Learning from Medical Errors: Clinical Problems which focuses on the most common clinical situations resulting in malpractice litigation. Learning from Medical Errors: Legal Issues is vital reading for all doctors, medical lecturers and teachers and medical lawyers.

Advances in Patient Safety

Author : Kerm Henriksen
Publisher : Unknown
Page : 526 pages
File Size : 54,6 Mb
Release : 2005
Category : Medical
ISBN : CHI:70548902

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Advances in Patient Safety by Kerm Henriksen Pdf

v. 1. Research findings -- v. 2. Concepts and methodology -- v. 3. Implementation issues -- v. 4. Programs, tools and products.

Resident Duty Hours

Author : Institute of Medicine,Committee on Optimizing Graduate Medical Trainee (Resident) Hours and Work Schedules to Improve Patient Safety
Publisher : National Academies Press
Page : 427 pages
File Size : 46,7 Mb
Release : 2009-04-27
Category : Medical
ISBN : 9780309131520

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Resident Duty Hours by Institute of Medicine,Committee on Optimizing Graduate Medical Trainee (Resident) Hours and Work Schedules to Improve Patient Safety Pdf

Medical residents in hospitals are often required to be on duty for long hours. In 2003 the organization overseeing graduate medical education adopted common program requirements to restrict resident workweeks, including limits to an average of 80 hours over 4 weeks and the longest consecutive period of work to 30 hours in order to protect patients and residents from unsafe conditions resulting from excessive fatigue. Resident Duty Hours provides a timely examination of how those requirements were implemented and their impact on safety, education, and the training institutions. An in-depth review of the evidence on sleep and human performance indicated a need to increase opportunities for sleep during residency training to prevent acute and chronic sleep deprivation and minimize the risk of fatigue-related errors. In addition to recommending opportunities for on-duty sleep during long duty periods and breaks for sleep of appropriate lengths between work periods, the committee also recommends enhancements of supervision, appropriate workload, and changes in the work environment to improve conditions for safety and learning. All residents, medical educators, those involved with academic training institutions, specialty societies, professional groups, and consumer/patient safety organizations will find this book useful to advocate for an improved culture of safety.

Patient Safety and Quality

Author : Ronda Hughes
Publisher : Department of Health and Human Services
Page : 592 pages
File Size : 47,8 Mb
Release : 2008
Category : Medical
ISBN : IOWA:31858055672798

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Patient Safety and Quality by Ronda Hughes Pdf

"Nurses play a vital role in improving the safety and quality of patient car -- not only in the hospital or ambulatory treatment facility, but also of community-based care and the care performed by family members. Nurses need know what proven techniques and interventions they can use to enhance patient outcomes. To address this need, the Agency for Healthcare Research and Quality (AHRQ), with additional funding from the Robert Wood Johnson Foundation, has prepared this comprehensive, 1,400-page, handbook for nurses on patient safety and quality -- Patient Safety and Quality: An Evidence-Based Handbook for Nurses. (AHRQ Publication No. 08-0043)." - online AHRQ blurb, http://www.ahrq.gov/qual/nurseshdbk/

Learning from Medical Errors

Author : Anh Vu T. Nguyen,Dung A. Nguyen
Publisher : Radcliffe Publishing
Page : 258 pages
File Size : 51,5 Mb
Release : 2005
Category : Clinical competence
ISBN : 185775767X

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Learning from Medical Errors by Anh Vu T. Nguyen,Dung A. Nguyen Pdf

Focuses on the key legal issues including medical documentation, which reduce risk and liability when handled correctly. This book contains chapters on difficult patients and special issues for emergency physicians. The case-based format demonstrates clinical relevance, and useful examples are drawn from office, hospital and community settings.

Improving Diagnosis in Health Care

Author : National Academies of Sciences, Engineering, and Medicine,Institute of Medicine,Board on Health Care Services,Committee on Diagnostic Error in Health Care
Publisher : National Academies Press
Page : 473 pages
File Size : 44,5 Mb
Release : 2015-12-29
Category : Medical
ISBN : 9780309377720

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Improving Diagnosis in Health Care by National Academies of Sciences, Engineering, and Medicine,Institute of Medicine,Board on Health Care Services,Committee on Diagnostic Error in Health Care Pdf

Getting the right diagnosis is a key aspect of health care - it provides an explanation of a patient's health problem and informs subsequent health care decisions. The diagnostic process is a complex, collaborative activity that involves clinical reasoning and information gathering to determine a patient's health problem. According to Improving Diagnosis in Health Care, diagnostic errors-inaccurate or delayed diagnoses-persist throughout all settings of care and continue to harm an unacceptable number of patients. It is likely that most people will experience at least one diagnostic error in their lifetime, sometimes with devastating consequences. Diagnostic errors may cause harm to patients by preventing or delaying appropriate treatment, providing unnecessary or harmful treatment, or resulting in psychological or financial repercussions. The committee concluded that improving the diagnostic process is not only possible, but also represents a moral, professional, and public health imperative. Improving Diagnosis in Health Care, a continuation of the landmark Institute of Medicine reports To Err Is Human (2000) and Crossing the Quality Chasm (2001), finds that diagnosis-and, in particular, the occurrence of diagnostic errorsâ€"has been largely unappreciated in efforts to improve the quality and safety of health care. Without a dedicated focus on improving diagnosis, diagnostic errors will likely worsen as the delivery of health care and the diagnostic process continue to increase in complexity. Just as the diagnostic process is a collaborative activity, improving diagnosis will require collaboration and a widespread commitment to change among health care professionals, health care organizations, patients and their families, researchers, and policy makers. The recommendations of Improving Diagnosis in Health Care contribute to the growing momentum for change in this crucial area of health care quality and safety.

Medical Errors and Medical Narcissism

Author : John D. Banja
Publisher : Jones & Bartlett Learning
Page : 246 pages
File Size : 44,5 Mb
Release : 2004
Category : Medical errors
ISBN : 0763783617

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Medical Errors and Medical Narcissism by John D. Banja Pdf

Using the concept of medical narcissism the author examines both the psychological and biological factors involved when a physician decides not to disclose when a medical error has occurred.

Teamwork in Healthcare

Author : Michael S. Firstenberg,Stanislaw P. Stawicki
Publisher : BoD – Books on Demand
Page : 194 pages
File Size : 48,9 Mb
Release : 2021-04-21
Category : Business & Economics
ISBN : 9781838810283

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Teamwork in Healthcare by Michael S. Firstenberg,Stanislaw P. Stawicki Pdf

One of the most important advances in the delivery of healthcare has been recognition of the need for developing highly functioning multi-disciplinary teams. Such teams, when structured in a cohesive fashion, can function more effectively and efficiently than the sum of their parts. The benefits of teamwork extend from the delivery of care to a single patient to the overall structure and function of entire care delivery systems. Recognizing the value of collaborative approaches for improving all aspects of healthcare delivery and having champions, leaders, structure, function, goals, and accountability are paramount to success, regardless of how defined. Another important pillar of teamwork is excellent communication with clearly defined information flows and cross-verification mechanisms. This book outlines how to work together for shared goals in a complex, diverse, and constantly evolving health care system.

Talking with Patients and Families about Medical Error

Author : Robert D. Truog,David M. Browning,Judith A. Johnson,Thomas H. Gallagher
Publisher : JHU Press
Page : 198 pages
File Size : 41,6 Mb
Release : 2011-01-17
Category : Medical
ISBN : 9781421401027

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Talking with Patients and Families about Medical Error by Robert D. Truog,David M. Browning,Judith A. Johnson,Thomas H. Gallagher Pdf

More than a million patient safety incidents occur every year, and medical error is the third leading cause of death in the United States. Illuminating the experiences of those affected by medical error—patients, their loved ones, and physicians and other medical professionals—Talking with Patients and Families about Medical Error delves deeply into the challenges of communicating honestly and openly about mistakes in medical practice. cc Based on guidelines from the Institute for Professional and Ethical Practice and the authors' own experiences, the practice-based approaches outlined here offer concrete guidance on • initiating discussions • dealing professionally and compassionately with patients' reactions • who should be included in the conversation • what information should be documented in the medical record • how to respond to questions about financial compensation Aimed at promoting resolution and healing, this book stresses the importance of clear, empathetic communication that will improve clinical and organizational responses to medical missteps and mismanagement. It emphasizes five features of the physician-patient relationship deserving of special attention: transparency, respect, accountability, continuity, and kindness (TRACK). Narrative examples of common situations demonstrate how conversations about medical error can lead to healing.

Medication Errors

Author : Robert Naylor
Publisher : Radcliffe Publishing
Page : 356 pages
File Size : 49,6 Mb
Release : 2002
Category : Chemotherapy
ISBN : 1857759567

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Medication Errors by Robert Naylor Pdf

This text looks at the incidence of adverse drug reactions and medication errors in hospitals and primary care, when such errors occur, the cost of medical errors, how to reduce errors, and the implications of error reduction.

Preventing Medication Errors

Author : Institute of Medicine,Board on Health Care Services,Committee on Identifying and Preventing Medication Errors
Publisher : National Academies Press
Page : 481 pages
File Size : 41,5 Mb
Release : 2007-01-11
Category : Medical
ISBN : 9780309101479

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Preventing Medication Errors by Institute of Medicine,Board on Health Care Services,Committee on Identifying and Preventing Medication Errors Pdf

In 1996 the Institute of Medicine launched the Quality Chasm Series, a series of reports focused on assessing and improving the nation's quality of health care. Preventing Medication Errors is the newest volume in the series. Responding to the key messages in earlier volumes of the seriesâ€"To Err Is Human (2000), Crossing the Quality Chasm (2001), and Patient Safety (2004)â€"this book sets forth an agenda for improving the safety of medication use. It begins by providing an overview of the system for drug development, regulation, distribution, and use. Preventing Medication Errors also examines the peer-reviewed literature on the incidence and the cost of medication errors and the effectiveness of error prevention strategies. Presenting data that will foster the reduction of medication errors, the book provides action agendas detailing the measures needed to improve the safety of medication use in both the short- and long-term. Patients, primary health care providers, health care organizations, purchasers of group health care, legislators, and those affiliated with providing medications and medication- related products and services will benefit from this guide to reducing medication errors.

Avoiding Medical Errors

Author : Robert M. Fox,Chris Landon
Publisher : Rowman & Littlefield
Page : 206 pages
File Size : 46,8 Mb
Release : 2020-04-08
Category : Health & Fitness
ISBN : 9781538135723

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Avoiding Medical Errors by Robert M. Fox,Chris Landon Pdf

This book, written by a lawyer and a doctor explains to everyday readers ways in which they can avoid death and injury caused by medical mistakes. It may be shocking to learn that preventable errors by doctor and hospital personnel are a leading cause of death and injury in the United States—perhaps even exceeding the annual deaths caused by heart disease and cancer. But avoiding these mistakes is possible, and the rules found in this book will arm readers against the careless errors that lead to such deaths and injuries. From hospitals to doctors’ offices, medical professionals are overwhelmed, overtired, even overworked and mistakes are sometimes unavoidable even with the best safety measures in place. A resident at the end of a 36-hour on-call stint may forget to wash her hands before performing a surgical procedure. A chart may be mismarked. Medications may be inaccurately listed. Test results may be inaccurately interpreted. But patients are in a position to help themselves and their medical caregivers to avoid these mistakes by taking more active and attentive part in their own healthcare. By being aware of the most common errors, patients can look for ways to ask questions, review information, even examine test results with a critical eye toward their own health and specific situations. Robert Fox and Chris Landon show them how.

Impact of Medical Errors and Malpractice on Health Economics, Quality, and Patient Safety

Author : Riga, Marina
Publisher : IGI Global
Page : 334 pages
File Size : 52,6 Mb
Release : 2017-01-30
Category : Medical
ISBN : 9781522523383

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Impact of Medical Errors and Malpractice on Health Economics, Quality, and Patient Safety by Riga, Marina Pdf

Precise and flawless medical practice is imperative due to the delicate nature of patient lives and health. Without methods and technologies to detect medical mistakes, many lives would be compromised. Impact of Medical Errors and Malpractice on Health Economics, Quality, and Patient Safety is an essential reference source for the latest research on the detection and analysis of the various implications of medical errors and addresses the hidden malpractices that exist in healthcare systems globally. Featuring extensive coverage on a broad range of topics such as clinical pathways, decision-making techniques, and health information technology, this book is ideally designed for practitioners, professionals, and researchers seeking current research on various issues in healthcare provision.

Learning from Medical Errors

Author : Anh Vu Nguyen,Dung Nguyen
Publisher : CRC Press
Page : 265 pages
File Size : 42,9 Mb
Release : 2018-10-08
Category : Medical
ISBN : 9781315342528

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Learning from Medical Errors by Anh Vu Nguyen,Dung Nguyen Pdf

The upheavals of the NHS reforms have caused a great deal of stress and uncertainty in primary care, and professional development and support for general practitioners needs to take account of this. This book offers a group supervision model which can be used to develop the core competencies needed for GPs to make the new primary care organisations work. The book analyses how primary care professionals have dealt with the various reforms of the past decade, and picks apart the paralysing culture of politeness, conflict avoidance and rivalry for power, to reveal how at the core of reform is the struggle for each GP to construct a new professional identity which integrates medicine, management and politics.It proposes ways GPs can benefit from these experiences to become equipped with the necessary competencies to be active members or dynamic leaders in the new primary care organisations. The doctor-patient relationship is no longer one-to-one, but located within a group matrix, in the same way that a GP is now required to work within a group framework. This book enables GPs to develop the essential group skills they now need, and on which the success of the healthcare reforms ultimately depends. 'A challenging approach to understanding and supporting the individuals who make up the primary care workforce. Gerhard Wilke has drawn on his experiences to identify the reasons behind the 'dis-ease' felt by many practitioners, and to suggest models for improving their morale. This book will be of interest to practitioners working through the challenges of continuing 'top down' reorganisation of the NHS and responding to the reconfiguration of general practice partnerships into PCGs and PCTs.'