To Err Is Human

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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 : 40,5 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

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 : 52,7 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.

The Poet's Mistake

Author : Erica McAlpine
Publisher : Princeton University Press
Page : 296 pages
File Size : 51,7 Mb
Release : 2020-06-09
Category : Literary Criticism
ISBN : 9780691203768

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The Poet's Mistake by Erica McAlpine Pdf

What our tendency to justify the mistakes in poems reveals about our faith in poetry—and about how we read Keats mixed up Cortez and Balboa. Heaney misremembered the name of one of Wordsworth's lakes. Poetry—even by the greats—is rife with mistakes. In The Poet's Mistake, critic and poet Erica McAlpine gathers together for the first time numerous instances of these errors, from well-known historical gaffes to never-before-noticed grammatical incongruities, misspellings, and solecisms. But unlike the many critics and other readers who consider such errors felicitous or essential to the work itself, she makes a compelling case for calling a mistake a mistake, arguing that denying the possibility of error does a disservice to poets and their poems. Tracing the temptation to justify poets' errors from Aristotle through Freud, McAlpine demonstrates that the study of poetry's mistakes is also a study of critical attitudes toward mistakes, which are usually too generous—and often at the expense of the poet's intentions. Through remarkable close readings of Wordsworth, Keats, Browning, Clare, Dickinson, Crane, Bishop, Heaney, Ashbery, and others, The Poet's Mistake shows that errors are an inevitable part of poetry's making and that our responses to them reveal a great deal about our faith in poetry—and about how we read.

Crossing the Quality Chasm

Author : Institute of Medicine,Committee on Quality of Health Care in America
Publisher : National Academies Press
Page : 360 pages
File Size : 43,5 Mb
Release : 2001-08-19
Category : Medical
ISBN : 9780309072809

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Crossing the Quality Chasm by Institute of Medicine,Committee on Quality of Health Care in America Pdf

Second in a series of publications from the Institute of Medicine's Quality of Health Care in America project Today's health care providers have more research findings and more technology available to them than ever before. Yet recent reports have raised serious doubts about the quality of health care in America. Crossing the Quality Chasm makes an urgent call for fundamental change to close the quality gap. This book recommends a sweeping redesign of the American health care system and provides overarching principles for specific direction for policymakers, health care leaders, clinicians, regulators, purchasers, and others. In this comprehensive volume the committee offers: A set of performance expectations for the 21st century health care system. A set of 10 new rules to guide patient-clinician relationships. A suggested organizing framework to better align the incentives inherent in payment and accountability with improvements in quality. Key steps to promote evidence-based practice and strengthen clinical information systems. Analyzing health care organizations as complex systems, Crossing the Quality Chasm also documents the causes of the quality gap, identifies current practices that impede quality care, and explores how systems approaches can be used to implement change.

Blue Threat

Author : Tony Kern
Publisher : Unknown
Page : 256 pages
File Size : 54,8 Mb
Release : 2009-09
Category : Attention
ISBN : 0984206302

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Blue Threat by Tony Kern Pdf

Health IT and Patient Safety

Author : Institute of Medicine,Board on Health Care Services,Committee on Patient Safety and Health Information Technology
Publisher : National Academies Press
Page : 234 pages
File Size : 44,5 Mb
Release : 2012-04-15
Category : Computers
ISBN : 9780309221122

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Health IT and Patient Safety by Institute of Medicine,Board on Health Care Services,Committee on Patient Safety and Health Information Technology Pdf

IOM's 1999 landmark study To Err is Human estimated that between 44,000 and 98,000 lives are lost every year due to medical errors. This call to action has led to a number of efforts to reduce errors and provide safe and effective health care. Information technology (IT) has been identified as a way to enhance the safety and effectiveness of care. In an effort to catalyze its implementation, the U.S. government has invested billions of dollars toward the development and meaningful use of effective health IT. Designed and properly applied, health IT can be a positive transformative force for delivering safe health care, particularly with computerized prescribing and medication safety. However, if it is designed and applied inappropriately, health IT can add an additional layer of complexity to the already complex delivery of health care. Poorly designed IT can introduce risks that may lead to unsafe conditions, serious injury, or even death. Poor human-computer interactions could result in wrong dosing decisions and wrong diagnoses. Safe implementation of health IT is a complex, dynamic process that requires a shared responsibility between vendors and health care organizations. Health IT and Patient Safety makes recommendations for developing a framework for patient safety and health IT. This book focuses on finding ways to mitigate the risks of health IT-assisted care and identifies areas of concern so that the nation is in a better position to realize the potential benefits of health IT. Health IT and Patient Safety is both comprehensive and specific in terms of recommended options and opportunities for public and private interventions that may improve the safety of care that incorporates the use of health IT. This book will be of interest to the health IT industry, the federal government, healthcare providers and other users of health IT, and patient advocacy groups.

Bozo Sapiens

Author : Michael Kaplan,Ellen Kaplan
Publisher : Bloomsbury Publishing USA
Page : 302 pages
File Size : 46,8 Mb
Release : 2010-08-24
Category : Science
ISBN : 9781608190911

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Bozo Sapiens by Michael Kaplan,Ellen Kaplan Pdf

A lighthearted survey of the science of mistakes by the authors of Chances Are reveals how the human race is hard-wired to get things wrong in countless ways, citing such examples as successful racy advertisements for inferior products, our inclinations to favor dysfunctional relationship partners and the socially unacceptable behaviors of leaders. Reprint.

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 : 51,6 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.

Still Not Safe

Author : Robert Wears
Publisher : Oxford University Press, USA
Page : 305 pages
File Size : 42,6 Mb
Release : 2019-12
Category : Medical
ISBN : 9780190271268

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Still Not Safe by Robert Wears Pdf

The term "patient safety" rose to popularity in the late nineties, as the medical community -- in particular, physicians working in nonmedical and administrative capacities -- sought to raise awareness of the tens of thousands of deaths in the US attributed to medical errors each year. But what was causing these medical errors? And what made these accidents to rise to epidemic levels, seemingly overnight? Still Not Safe is the story of the rise of the patient-safety movement -- and how an "epidemic" of medical errors was derived from a reality that didn't support such a characterization. Physician Robert Wears and organizational theorist Kathleen Sutcliffe trace the origins of patient safety to the emergence of market trends that challenged the place of doctors in the larger medical ecosystem: the rise in medical litigation and physicians' aversion to risk; institutional changes in the organization and control of healthcare; and a bureaucratic movement to "rationalize" medical practice -- to make a hospital run like a factory. If these social factors challenged the place of practitioners, then the patient-safety movement provided a means for readjustment. In spite of relatively constant rates of medical errors in the preceding decades, the "epidemic" was announced in 1999 with the publication of the Institute of Medicine report To Err Is Human; the reforms that followed came to be dominated by the very professions it set out to reform. Weaving together narratives from medicine, psychology, philosophy, and human performance, Still Not Safe offers a counterpoint to the presiding, doctor-centric narrative of contemporary American medicine. It is certain to raise difficult, important questions around the state of our healthcare system -- and provide an opening note for other challenging conversations.

Cross-cultural Perspectives in Medical Ethics

Author : Robert M. Veatch
Publisher : Jones & Bartlett Learning
Page : 404 pages
File Size : 54,8 Mb
Release : 2000
Category : Cross-cultural comparison
ISBN : 0763713325

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Cross-cultural Perspectives in Medical Ethics by Robert M. Veatch Pdf

Cross- Cultural Perspectives in Medical Ethics, Second Edition, is an anthology of the latest and best readings on the medical ethics of as many of the major religious, philosophical, and medical traditions that are available today.

Human Error in Medicine

Author : Marilyn Sue Bogner
Publisher : CRC Press
Page : 529 pages
File Size : 41,7 Mb
Release : 2018-02-06
Category : Technology & Engineering
ISBN : 9781351440202

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Human Error in Medicine by Marilyn Sue Bogner Pdf

This edited collection of articles addresses aspects of medical care in which human error is associated with unanticipated adverse outcomes. For the purposes of this book, human error encompasses mismanagement of medical care due to: * inadequacies or ambiguity in the design of a medical device or institutional setting for the delivery of medical care; * inappropriate responses to antagonistic environmental conditions such as crowding and excessive clutter in institutional settings, extremes in weather, or lack of power and water in a home or field setting; * cognitive errors of omission and commission precipitated by inadequate information and/or situational factors -- stress, fatigue, excessive cognitive workload. The first to address the subject of human error in medicine, this book considers the topic from a problem oriented, systems perspective; that is, human error is considered not as the source of the problem, but as a flag indicating that a problem exists. The focus is on the identification of the factors within the system in which an error occurs that contribute to the problem of human error. As those factors are identified, efforts to alleviate them can be instituted and reduce the likelihood of error in medical care. Human error occurs in all aspects of human activity and can have particularly grave consequences when it occurs in medicine. Nearly everyone at some point in life will be the recipient of medical care and has the possibility of experiencing the consequences of medical error. The consideration of human error in medicine is important because of the number of people that are affected, the problems incurred by such error, and the societal impact of such problems. The cost of those consequences to the individuals involved in medical error, both in the health care providers' concern and the patients' emotional and physical pain, the cost of care to alleviate the consequences of the error, and the cost to society in dollars and in lost personal contributions, mandates consideration of ways to reduce the likelihood of human error in medicine. The chapters were written by leaders in a variety of fields, including psychology, medicine, engineering, cognitive science, human factors, gerontology, and nursing. Their experience was gained through actual hands-on provision of medical care and/or research into factors contributing to error in such care. Because of the experience of the chapter authors, their systematic consideration of the issues in this book affords the reader an insightful, applied approach to human error in medicine -- an approach fortified by academic discipline.

Keeping Patients Safe

Author : Institute of Medicine,Board on Health Care Services,Committee on the Work Environment for Nurses and Patient Safety
Publisher : National Academies Press
Page : 485 pages
File Size : 49,8 Mb
Release : 2004-03-27
Category : Medical
ISBN : 9780309187367

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Keeping Patients Safe by Institute of Medicine,Board on Health Care Services,Committee on the Work Environment for Nurses and Patient Safety Pdf

Building on the revolutionary Institute of Medicine reports To Err is Human and Crossing the Quality Chasm, Keeping Patients Safe lays out guidelines for improving patient safety by changing nurses' working conditions and demands. Licensed nurses and unlicensed nursing assistants are critical participants in our national effort to protect patients from health care errors. The nature of the activities nurses typically perform â€" monitoring patients, educating home caretakers, performing treatments, and rescuing patients who are in crisis â€" provides an indispensable resource in detecting and remedying error-producing defects in the U.S. health care system. During the past two decades, substantial changes have been made in the organization and delivery of health care â€" and consequently in the job description and work environment of nurses. As patients are increasingly cared for as outpatients, nurses in hospitals and nursing homes deal with greater severity of illness. Problems in management practices, employee deployment, work and workspace design, and the basic safety culture of health care organizations place patients at further risk. This newest edition in the groundbreaking Institute of Medicine Quality Chasm series discusses the key aspects of the work environment for nurses and reviews the potential improvements in working conditions that are likely to have an impact on patient safety.

Making Healthcare Safe

Author : Lucian L. Leape
Publisher : Springer Nature
Page : 450 pages
File Size : 45,6 Mb
Release : 2021-05-28
Category : Medical
ISBN : 9783030711238

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Making Healthcare Safe by Lucian L. Leape Pdf

This unique and engaging open access title provides a compelling and ground-breaking account of the patient safety movement in the United States, told from the perspective of one of its most prominent leaders, and arguably the movement’s founder, Lucian L. Leape, MD. Covering the growth of the field from the late 1980s to 2015, Dr. Leape details the developments, actors, organizations, research, and policy-making activities that marked the evolution and major advances of patient safety in this time span. In addition, and perhaps most importantly, this book not only comprehensively details how and why human and systems errors too often occur in the process of providing health care, it also promotes an in-depth understanding of the principles and practices of patient safety, including how they were influenced by today’s modern safety sciences and systems theory and design. Indeed, the book emphasizes how the growing awareness of systems-design thinking and the self-education and commitment to improving patient safety, by not only Dr. Leape but a wide range of other clinicians and health executives from both the private and public sectors, all converged to drive forward the patient safety movement in the US. Making Healthcare Safe is divided into four parts: I. In the Beginning describes the research and theory that defined patient safety and the early initiatives to enhance it. II. Institutional Responses tells the stories of the efforts of the major organizations that began to apply the new concepts and make patient safety a reality. Most of these stories have not been previously told, so this account becomes their histories as well. III. Getting to Work provides in-depth analyses of four key issues that cut across disciplinary lines impacting patient safety which required special attention. IV. Creating a Culture of Safety looks to the future, marshalling the best thinking about what it will take to achieve the safe care we all deserve. Captivatingly written with an “insider’s” tone and a major contribution to the clinical literature, this title will be of immense value to health care professionals, to students in a range of academic disciplines, to medical trainees, to health administrators, to policymakers and even to lay readers with an interest in patient safety and in the critical quest to create safe care.

Patient Safety

Author : Institute of Medicine,Board on Health Care Services,Committee on Data Standards for Patient Safety
Publisher : National Academies Press
Page : 551 pages
File Size : 41,5 Mb
Release : 2003-12-20
Category : Medical
ISBN : 9780309090773

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Patient Safety by Institute of Medicine,Board on Health Care Services,Committee on Data Standards for Patient Safety Pdf

Americans should be able to count on receiving health care that is safe. To achieve this, a new health care delivery system is needed â€" a system that both prevents errors from occurring, and learns from them when they do occur. The development of such a system requires a commitment by all stakeholders to a culture of safety and to the development of improved information systems for the delivery of health care. This national health information infrastructure is needed to provide immediate access to complete patient information and decision-support tools for clinicians and their patients. In addition, this infrastructure must capture patient safety information as a by-product of care and use this information to design even safer delivery systems. Health data standards are both a critical and time-sensitive building block of the national health information infrastructure. Building on the Institute of Medicine reports To Err Is Human and Crossing the Quality Chasm, Patient Safety puts forward a road map for the development and adoption of key health care data standards to support both information exchange and the reporting and analysis of patient safety data.

Dictionary of Global Bioethics

Author : Henk ten Have,Maria do Céu Patrão Neves
Publisher : Springer Nature
Page : 1063 pages
File Size : 45,7 Mb
Release : 2021-05-26
Category : Philosophy
ISBN : 9783030541613

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Dictionary of Global Bioethics by Henk ten Have,Maria do Céu Patrão Neves Pdf

This Dictionary presents a broad range of topics relevant in present-day global bioethics. With more than 500 entries, this dictionary covers organizations working in the field of global bioethics, international documents concerning bioethics, personalities that have played a role in the development of global bioethics, as well as specific topics in the field.The book is not only useful for students and professionals in global health activities, but can also serve as a basic tool that explains relevant ethical notions and terms. The dictionary furthers the ideals of cosmopolitanism: solidarity, equality, respect for difference and concern with what human beings- and specifically patients - have in common, regardless of their backgrounds, hometowns, religions, gender, etc. Global problems such as pandemic diseases, disasters, lack of care and medication, homelessness and displacement call for global responses.This book demonstrates that a moral vision of global health is necessary and it helps to quickly understand the basic ideas of global bioethics.