Joint Commission and general books and articles related to sentinel events.
Andrews LB, et al: An alternative strategy for studying adverse events in medical care. The Lancet 349:309-313, 1997.
Authors undertook a prospective, observational study of care of patients admitted to three units of a large urban teaching hospital. Of 1,047 patients, 185 (18%) had at least one serious adverse event. Patients with long stays had more AEs. The likelihood of experiencing an AE increased 6% for each day of stay. Most of the mistakes (28%) were made during monitoring and daily care; 10% happened during surgery. Intensive care patients were most likely to have major complications caused by errors.
Baker HM: Rules outside the rules for administration of medication: a study in New South Wales, Australia. Image 29:155-8, 1997.
This study’s findings provide a body of tacitly held knowledge about medication error that is shared among clinical nurses and redefines medication error using six criteria. The study calls into question the way institutions seek to identify, document, and reduce medication errors by nurses and the validity of nursing research based on reported error rates.
Barker KN, Allan EL: Research on drug-use-system errors. Am J Health Syst Pharm 52:400-403, 1995.
Reports on ongoing research on medication errors at Auburn University.
Bates DW, et al: Asking residents about adverse events in a computer dialogue: how accurate are they? Jt Comm J Qual Improv 24:197-202, 1998.
Reports on a demonstration study that suggests that electronic medical records can be used to screen for and ask physicians questions about adverse events.
Bates DW: Drugs and adverse drug reactions; how worried should we be? JAMA, 279:1216-1217, 1998.
This editorial comment to a study conducted by Lazarou criticizes that study’s methodology, but agrees that ADRs represent an important clinical issue. Author suggests that computerized surveillance systems (although still works-in-progress) should help to cut the frequency of ADRs. (See Lazarou for study)
Bates DW, et al: The costs of adverse drug events in hospitalized patients. JAMA, 277:307-311, 1997.
This study assessed the additional resource utilization associated with ADEs. The substantial costs of ADEs justify investment in efforts to prevent these events. Moreover, these estimates are conservative because they do not include the costs of injuries to patients or malpractice costs.
Bates DW, et al: Evaluation of screening criteria for adverse events in medical patients. Med Care 33:452-462, 1995.
Evaluates the sensitivity and specificity of 15 screening criteria for adverse events, preventable adverse events, and severe adverse events in medical patients, as well as combinations of these criteria.
Bates DW, et al: Incidence of adverse drug events and potential adverse drug events; implications for prevention. JAMA 274:29-34, 1995.
Studied the incidence and preventability of adverse drug events and potential ADEs. Found that adverse drug events were common and often preventable. Serious ADEs were more likely to be preventable. Most resulted from errors at the ordering stage, but many also occurred at the administration stage. (See also Kahn for editorial comment; see also Leape (1995))
Bates DW, et al: Relationship between medication errors and adverse drug events. J Gen Intern Med 10:199-205, 1995.
Evaluated the frequency of medication errors using a multidisciplinary approach, classified these errors by type, and determined how often medication errors are associated with adverse drug events. Found that medication errors are common, although relatively few result in ADEs. However, those that do are preventable, many through physician computer order entry.
Belkin L: How can we save the next victim? New York Times Magazine, June 15, 1997, pp.28-70, passim.
Examines recent notable medical errors and focuses on designing systems so errors are caught before they reach the patient.
Blecher MB: Accident scenes. Hosp Health Netw 71(10):46-8, 1997.
Reports on a behind-the-scenes study that found that mixed incentives within a hospital’s culture were hiding patterns of errors. About 38% of serious errors never came to the administrator’s attention.
Blumenthal D: Making medical errors into "medical treasures". JAMA 272:1867-1868, 1994.
This editorial calls for physicians to play a more constructive role in error prevention. Physicians owe it to their patients and themselves to use the science of error prevention to improve the practice of medicine. (Commentary on Leape (1994))
Bradbury K, et al: Prevention of medication errors: developing a continuous-quality-improvement approach. Mt Sinai J Med 60:379-386, 1993.
Provides an overview of the medication error problem, including prevalence, system for categorization, roles of various providers in prevention, and the development of a CQI program to address the issue in large teaching hospitals.
Brennan TA, et al: Identification of adverse events occurring during hospitalization. Ann Intern Med 112:221-226, 1990.
This study found that the overwhelming majority of adverse events and episodes of negligent care are discoverable with the use of the medical record review. Medical record review had a sensitivity of 80% for discovering adverse events and a sensitivity of 76% for discovering negligent care.
Brennan TA, et al: Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med 324:370-376, 1991.
This study found that adverse events occurred in 3.7% of the hospitalizations studied, and 27.6% of the adverse events were due to negligence. (See Leape (1991) for Part II)
Campbell GM, Facchinetti NJ: Using process control charts to monitor dispensing and checking errors. Am J Health-Syst Pharm 55:946-954, 1998.
Authors propose using statistical process control methods to monitor medication errors, separating dispensing and checking processes. They propose a model using artificial errors in dispensing to determine error rate in checking.
Christensen JF, Levinson W, Dunn PM: The heart of darkness: The impact of perceived mistakes on physicians. J Gen Intern Med 7:424-431, 1992.
Describes how physicians think and feel about their perceived mistakes and examines how physicians’ prior beliefs and manners of coping with mistakes may influence their emotional responses.
Classen DC, et al.: Adverse drug events in hospitalized patients; excess length of stay, extra costs, and attributable mortality. JAMA 277:301-306, 1997.
This study at LDS Hospital found that ADEs complicated 2.43 per 100 admissions. An ADE is associated with a significantly prolonged length of stay, increased economic burden, and an almost 2-fold increased risk of death.
Cohen MR, et al: Preventing medication errors in cancer chemotherapy. Am J Health-Syst Pharm, 53:737-746, 1996.
Offers specific steps to minimize the risk of medication errors in cancer chemotherapy.
Cohen MR: Drug product characteristics that foster drug-use-system errors. Am J Health-Syst Pharm 52:395-399, 1995.
Examines various product characteristics that may foster drug errors, including packaging, nonexistent warning systems, look-alike labeling, nomenclature, and faulty design of devices.
Cooper JB: Is voluntary reporting of critical events effective for quality assurance? Anesthesiology 85:961-964, 1996.
This editorial suggests two necessary steps toward the encouragement of voluntary reporting of critical events: demonstrate the value of reporting and change the culture that attributes error to negligence. (See also Sanborn)
Cooper JB, Gaba DM: A strategy for preventing anesthesia accidents. Int Anesthesiol Clin 27(3):148-152, 1989.
Authors offer some suggestions for lowering the risk of adverse outcomes in anesthesia.
Cooper JB, et al: Preventable anesthesia mishaps: A study of human factors. Anesthesiology 49:399-406, 1978.
A modified critical-incident analysis technique was used in a retrospective examination of the characteristics of human error and equipment failure in anesthetic practice.
Cooper JB, Newbower RS, Ritz RJ: An analysis of major errors and equipment failures in anesthesia management—considerations for prevention and detection. Anesthesiology 60:34-42, 1984.
Summarizes a specific analysis of preventable mishaps that resulted in substantive negative outcomes and presents potential strategies for mitigation.
Cooper MC: Can a zero defects philosophy be applied to drug errors? J Adv Nurs 21:487-491, 1995.
Examines if a zero defects philosophy developed and used in industry can be transferred to health service, and concludes that it needs adaptation and cautious application. Some of the principles can be applied as individual quality initiatives.
Crane M: When a surgical mistake becomes a media event. Med Econ 16 (6): 44-51, 1997.
Rolando R. Sanchez, the surgeon who mistakenly amputated the wrong leg in Tampa in 1995, tells his side of the story. This case provides insight into how fail-safe systems broke down and allowed a preventable error to occur. It also illustrates how a physician can fall victim to a media furor.
Crane M: How good doctors can avoid bad errors. Med Econ 16 (5):16-21, 1997.
Some mistakes will always occur. But experts say most could be prevented by following some common sense rules and improving the system of checks and balances.
Cullen DJ, et al: Preventable adverse drug events in hospitalized patients: a comparative study of intensive care and general care units. Crit Care Med 25:1289-1297, 1997.
Authors found that the rate of preventable or potential ADEs was twice as high in intensive care units vs. non-ICUs. However, when adjusted for the number of drugs ordered, there was no significant difference. A stressed and overworked staff in an environment with many distractions was not the reason for the ADEs, but rather the quantity of drugs prescribed seemed to be a cause.
Cullen DJ, et al: The incident reporting system does not detect adverse drug events: A problem for quality improvement. Jt Comm J Qual Improv 21:541-548, 1995.
Authors describe how an incident reporting system for adverse drug events might be improved.
Davis NM: Editorial: Performance lapses as a cause of medication errors. Hosp Pharm 31:1524, 1527, 1996.
This first editorial in a series of three discusses six human factors that can cause performance-related errors.
Davis NM: Editorial: Lack of knowledge as a cause of medication errors. Hosp Pharm 32:16, 25, 1997.
This second editorial examines lack of knowledge as a second cause of medication errors and suggests some ways to combat it.
Davis NM: Editorial: Lack or failure of the safety net as a cause of medication errors. Hosp Pharm 32:143-144, 1997.
This third and final editorial deals with lack of, or failure of, a safety net as a cause of medication errors.
Elnitsky C: Are hospital incidents being reported? J Nurs Adm 27(11):40-46, 1997.
A survey of nurses working in acute care hospitals in 15 localities across a southeastern state was conducted to explore nurses’ hospital incident reporting behaviors. The number of incidents documented may represent only a portion of all incidents.
Feldman SE, Roblin, DW: Medical accidents in hospital care: applications of failure analysis to hospital quality appraisal. Jt Comm J Qual Improv 23:567-580, 1997.
Discusses what characteristics define the evolution of medical accidents and how quality appraisal in hospital care can be improved by analysis of medical accidents as a system problem.
Ferner RE: Is there a cure for drug errors? Br Med J 311(7003):463-464, 1995.
This editorial briefly offers simple things that can and should be done to eliminate drug errors.
Fleming ST: Complications, adverse events, and iatrogenesis: classifications and quality of care measurement issues. Clin Perform Qual Health Care 4(3):137-147, 1996.
Conceptualizes and differentiates among complications, adverse events, and iatrogenesis, and contemplates their use as measures of quality of care by proposing a three-level classification scheme and by examining the incidence, consequence, and determinants of these events.
Fletcher CE: Failure mode and effects analysis; an interdisciplinary way to analyze and reduce medication errors. J Nurs Adm 27(12):19-26, 1997.
Discusses use of Failure Mode and Effects Analysis, developed for use in high-risk industries, as an interdisciplinary approach to analyze and lessen medication errors.
Fox GN: Minimizing prescribing errors in infants and children. Am Fam Physician 53(4):1319-1325, 1996.
Examines common pediatric prescribing errors and strategies to prevent them.
Gaba DM: Human error in anesthetic mishaps. Int Anesthesiol Clin 27(3):137-147, 1989.
Author examines the kinds of errors made and how they can lead to accidents.
Gaba DM, DeAnda A: The response of anesthesia trainees to simulated critical incidents. Anesth Analg 68(4):444-451, 1989.
Authors studied the response of anesthesia trainees to five simulated critical incidents. Data suggest that some types of problems are harder to handle than others and that individuals vary widely in their problem-handling abilities.
Geraci JM, et al: Predicting the occurrence of adverse events after coronary artery bypass surgery. Ann Intern Med 118:18-24, 1993.
Examined whether adverse events occurring after CABG surgery can be predicted from clinical variables representing illness severity at admission. Found that severity of illness at admission has modest predictive power of adverse event occurrence.
Gladstone J: Drug administration errors: a study into the factors underlying the occurrence and reporting of drug errors in a district general hospital. J Adv Nurs 22:628-637, 1995.
Results from this study found that it was likely that many drug errors were not reported.
Haas D: In memory of Ben--a case study. Jt Comm Perspect 17(2):12-15, 1997.
This case study reviews a medication error resulting in the death of a seven year old boy at Martin Memorial Health System (Stuart, FL). Discusses the incident, the root cause analysis, and the operating room procedural changes that resulted.
Hackel R, Butt L, Banister G: How nurses perceive medication errors. Nurs Manage 27(1):31-34, 1996.
This study conducted at an urban community hospital found that medication errors are underreported and that nurses view medication errors as multiple cause incidents.
Helmrich RL: Human error in aviation: lessons for health care. Quality Connection 5(4):4-5, 1996.
Prints an interview with Robert Helmreich, professor of psychology at the University of Texas at Austin and director of a research project funded by the Federal Aviation Administration to study human error and develop strategies to manage human error.
Herrera CR, et al: Feasibility study of surveying the adverse drug reaction surveillance systems in a large community of hospitals. Ann Pharmacother 26:384-391, 1992.
This study found that the reporting of fatal and severe ADRs was more reliable than the reporting of moderate ADRs. These differences were due to inadequate documentation and the lack of a uniform definition of ADRs.
Hilfiker D: Facing our mistakes. N Engl J Med 310:118-122, 1984.
This doctor tells personal case studies of mistakes he has made in his private practice and the emotional effect these mistakes and their consequences have had on him.
Kahn KL: Above all ‘do no harm’; how shall we avoid errors in medicine?" JAMA 274:75-76, 1995.
This brief editorial offers some suggestions for decreasing the incidence of errors. (See also Bates (1995); see also Leape (1995)
Kelly WN: Pharmacy contributions to adverse medication events. Am J Health Syst Pharm 52:385-390, 1995.
Discusses how pharmacists and pharmacy systems sometimes contribute to negative patient outcomes.
Kravitz RL, Rolph JE, McGuigan K: Malpractice claims data as a quality improvement tool. I. Epidemiology of error in four specialties. JAMA 266:2087-2092, 1991.
This study found that malpractice data can be used to identify problem-prone clinical processes and suggest interventions that may reduce negligence. (See Rolph for Part II)
Lambert BL: Predicting look-alike and sound-alike medication errors. Am J Health Syst Pharm 54:1161-1171, 1997.
Describes a model for predicting medication name confusion, which causes many medication errors.
Lantos J: Should doctors tell the truth? Chicago Tribune Magazine, May 4, 1997:12-16, 26.
One physician gives his prescription for handling medical mistakes.
Lazarou J, et al.: Incidence of adverse drug reactions in hospitalized patients; a meta-analysis of prospective studies. JAMA 279:1200-1205, 1998.
Authors set out to estimate the incidence of serious and fatal adverse drug reactions (ADR) in hospital patients. They analyzed 39 prospective studies by a random-effects model. Their results showed an overall incidence of serious ADRs was 6.7% (2,216,000 in 1994) and of fatal ADRs was 0.32% (106,000 in 1994), making these reactions between the fourth and sixth leading cause of death. (See also Bates (1998) for editorial)
Leape LL: Error in medicine. JAMA 272:1851-1857, 1994.
Examines the mechanisms of medical errors and systems changes to reduce hospital injuries. (See also Blumenthal for editorial comment)
Leape LL, et al: The nature of adverse events in hospitalized patients: results of the Harvard Medical Practice Study II. N Engl J Med 324:377-384, 1991.
Analyzed a random sample of hospital records which identified 1,133 patients with adverse events in relation to error, negligence, and disability. Drug complications were the most common type of adverse event, followed by wound infections and technical complications. (See Brennan (1991) for Part I)
Leape LL, et al: Preventing medical injury. Qual Rev Bull 19:144-149, 1993.
Authors reviewed the patients who suffered adverse events in the Harvard Medical Practice Study to gain insight into factors associated with preventing adverse events.
Leape LL, et al: Systems analysis of adverse drug events. JAMA 274:35-43, 1995.
This study identified and evaluated the systems failures that underlie errors causing adverse drug events. The most common systems failure was in the dissemination of drug knowledge and inadequate availability of patient information. (See also Kahn for editorial comment; see also Bates (1995)
Lesar TS, et al: Factors related to errors in medication prescribing. JAMA 277:312-317, 1997.
Characterizes specific factors associated with medication prescribing errors by examining factors related to such errors detected and averted by pharmacists participating in an established medication error prevention program.
Levinson W, Dunn PM: A piece of my mind: coping with fallibility. JAMA 261:2252, 1989.
Most frequently, physicians’ mistakes do not come to public attention. This author addresses handling the guilt and emotional consequences of making an error.
Lilley LL, Guanci R: Med errors: applying systems theory. Am J Nurs 95(11):14-15, 1995.
Discusses the application of systems theory to discover flaws in the process of medication administration and prevent errors.
Lin B, Anderson LR: The role of the pharmacy department in the prevention of adverse drug events: a survey of current practices. Pharm Pract Manag Q 17 (1): 10-16, 1997.
The American Society of Health-System Pharmacists and the Institute for Safe Medication Practices have published recommendations on the prevention of adverse drug events in hospitals. This study provides an informative analysis of the status of implementation of these recommendations by hospital pharmacists in Louisiana.
Localio AR, et al: Identifying adverse events caused by medical care: degree of physician agreement in a retrospective chart review. Ann Intern Med 125:457-464, 1996.
Structured implicit reviews produced disagreement on the causes of adverse patient outcomes.
Marek CL: Avoiding prescribing errors: A systematic approach. J Am Dent Assoc 127:617-623, 1996.
Outlines eight pitfalls commonly encountered when writing prescriptions and urges dentists to adopt a systematic approach when prescribing.
Mills DH: Medical insurance feasibility study; a technical summary. West J Med 128:360-365, 1978.
Summarizes the California Medical Association’s Medical Insurance Feasibility Study which estimated the incidence of iatrogenic injury and substandard care. Researchers found a 4.6% rate of adverse events and a negligence rate of 0.8%.
Nadzam DM: Finding errors before they happen. Medsurg Nurs 6:370, 1997.
Outlines three approaches to minimize the risk of undesirable outcomes.
Nordhaus-Bike AM: A fix for drug errors. Hosp Health Netw 71(19):90, 92, 1997.
Working with forty health care organizations nationwide, the Institute for Healthcare Improvement found that many errors stem from the complexity of internal systems and employees’ failure to see how they added to the problem.
Pantaleo N, Talan M: Applying the performance improvement team concept to the medication order process. J Healthc Qual 20(2):30-35, 1998.
The pharmacy and medicine departments at one hospital took a proactive multidisciplinary approach that resulted in streamlining the medication order process, decreasing delays in initiating drug therapy, preventing ADEs, and employing cost-effective drug therapy.
Pepper GA: Errors in drug administration by nurses. Am J Health Syst Pharm 52:390-395, 1995.
Examines issues in understanding and preventing drug administration errors.
Petersen LA, et al: Does housestaff discontinuity of care increase the risk for preventable adverse events? Ann Intern Med 121:866-872, 1994.
This study found that potentially preventable adverse events were strongly associated with coverage by a physician from another team, which may reflect management by housestaff unfamiliar with the patient. These results emphasize the need for careful attention to the outcome of work-hour reforms for housestaff.
Phillips DA, et al: Increase in US medication-error deaths between 1983 and 1993. The Lancet 351 (9103):643-644, 1998.
This research has found that deaths from medication mistakes in the U.S. more than doubled between 1983 and 1993, with the greatest increase coming in deaths among outpatients.
Proulx S, et al: Medication error prevention: profiling one of pharmacy’s foremost advocacy efforts for advice on error prevention. Pharm Pract Manage Q 17 (1):1-9, 1997.
Reviews the work of the Institute for Safe Medication Practices (ISMP) and offers recommendations for error prevention strategies.
Rolph JE, et al: Malpractice claims data as a quality improvement tool. II. Is targeting effective? JAMA 266:2093-2097, 1991.
In this second half of a study, authors examined the concentration of clinically consequential errors. They concluded that use of physicians’ malpractice claims histories to target individuals for education or sanctions is problematic because of the only modest predictive power of such claims histories. (See Kravitz for Part I)
Roseman C, Booker JM: Workload and environmental factors in hospital medication errors. Nurs Res 44:226-230, 1995.
Examined nine hospital workload factors and seasonal changes in daylight and darkness over a five-year period in relation to nurse medication errors at a medical center in Anchorage, Alaska.
Sanborn KV, et al: Detection of intraoperative incidents by electronic scanning of computerized anesthesia records. Anesthesiology 85:977-987, 1996.
A low level of compliance with voluntary reporting of defined intraoperative incidents was found for all anesthesiologists studied. (See also Cooper (1996) for editorial)
Schiff GD: Commentary: diagnosis tracking and health reform. Am J Med Qual 9:149-152, 1994.
Ten examples illustrate key questions regarding misdiagnosis and a system for tracking admitting diagnosis revision is presented.
Schwid HA, O’Donnell D: Anesthesiologists’ management of simulated critical incidents. Anesthesiology 76:495-501, 1992.
Authors used an anesthesia simulator to create critical incidents to observe how anesthesiologists diagnose and treat in these situations.
Smetzer JL: Lesson from Colorado: beyond blaming individuals. Nursing ‘98 28(5):48-51, 1998.
The staff at the Institute for Safe Medication Practices performed an in-depth system analysis of a medication error and describe here some of the major system failures.
Senders JW: Detecting, correcting, and interrupting errors. J Intraven Nurs 18(1):28-32, 1995.
Author discusses some theoretical issues and suggests that understanding medical errors could be improved by giving up the custom of blaming people who make errors and, instead, attempting to gather as much information as possible. Some practical suggestions are offered for minimizing the effect of errors.
Sentinel events: approaches to error reduction and prevention. Jt Comm J Qual Improv 24:175-186, 1998.
This book excerpt describes practical strategies that organizations may pursue to reduce and prevent errors. Strategies include education and training, systems design or redesign, improvement of information management, teamwork, and self-assessment.
Trick OL: Adverse drug reactions: establishing a hierarchy of definitions for adjustment of report rates. Hosp Pharm 31:1593-1595, 1996.
Observing that the majority of hospitals underreport adverse drug reactions, the author outlines a two-step reporting process and a hierarchy of ADR definitions, which together facilitate more accurate reporting.
U.S. General Accounting Office: Medical device reporting: improvements needed in FDA’s systems for monitoring problems with approved devices. GAO/HEHS-97-21. Washington, DC: U.S. General Accounting Office, 1997.
This evaluative report reviewed FDA’s implementation of the Safe Medical Devices Act of 1990 and its medical device adverse event reporting system.
Valentine DR: Case review process using a systems approach. Int Anesthesiol Clin 30(2):15-27, 1992.
Describes the methodology of case review designed to identify system problems as well as individual practice patterns affecting patient care.
Van Leeuwen DH: Are medication error rates useful as comparative measures of organizational performance? Jt Comm J Qual Improv 20:192-199, 1994.
Results of this study show that currently measured error rates represent a process within an organization and can range from no or few errors to substantial errors, with the variation reflecting a variety of scenarios.
Veltman LL: Managing bad results. Group Pract J 46 (5):26-32, 1997.
Offers a structure and protocol for managing adverse outcomes in medical group practice.
Vincent C, Knox E: Clinical risk modification, quality, and patient safety: interrelationships, problems, and future potential. Best Practices and Benchmarking in Healthcare 2:221-226, 1997.
Discusses why existing quality initiatives have had little impact on iatrogenic injury and suggests an approach to clinical risk modification that may enhance the safety of medical treatment.
Willoughby C, Budreau G, Livingston D: A framework for integrated quality improvement. J Nurs Care Qual 11(3):44-53, 1997.
The Division of Psychiatric and Chemical Dependency Nursing at the University of Iowa Hospitals and Clinics presents a QI framework for the various components of a quality program and organizes these components into four broad categories: maintenance indicators, CQI activities, time-limited QI activities, and sentinel events. Includes a "Sentinel Event Follow-Up" form.
Wilson AL, et al: Computerized medication administration records decrease medication occurrences. Pharm Pract Manage Q 17(1):17-29, 1997.
Reports the results of a retrospective analysis to assess the improvements resulting from sharing a computerized medication record. The use of a shared medication record by pharmacy and nursing led to a statistically significant decrease in medication occurrences.
Wolf ZR, et al: Factors associated with a perceived harmful outcome from medication errors: a pilot study. J Contin Educ Nurs 27 (2):65-74, 1996.
This pilot study describes factors associated with a perceived harmful outcome following medication errors made by nurses and refines the Medication Error Risk Profile (MERP).
Wolff AM: Limited adverse occurrence screening: using medical record review to reduce hospital adverse patient events. Med J Aust 164(8):458-461, 1996.
This study found that the rate of adverse patient occurrences can be significantly reduced by their continuous detection using retrospective screening in conjunction with review, analysis and action to prevent recurrences.
Wolff AM: Limited adverse occurrence screening: an effective and efficient method of medical quality control. J Qual Clin Pract 15:221-233, 1995.
Studied the rate of adverse patient occurrences in a medium sized hospital and assessed the effectiveness and efficiency of limited adverse occurrence screening as a method of medical quality control.
Wu AW, et al: Do house officers learn from their mistakes? JAMA 265:2089-2094, 1991.
To learn how medical mistakes relate to subsequent changes in practice, authors surveyed 254 internal medicine house officers. Decreasing work load and closer supervision may help prevent mistakes. To promote learning, faculty should encourage house officers to accept responsibility and to discuss their mistakes.
Wu AW, et al: How house officers cope with their mistakes. West J Med 159(5):565-569, 1993.
Authors examined how house officers coped with serious medical mistakes to gain insight into how medical educators should handle these situations.
Wu AW, et al: To tell the truth. Ethical and practical issues in disclosing medical mistakes to patients. J Gen Intern Med 12:770-775, 1997.
Authors analyzed the various ethical arguments for and against disclosing serious mistakes to patients. They suggest that physicians have ethical obligations to disclose significant errors in all but rare cases. They provide practical suggestions for how to discuss the sensitive topic of mistakes with patients.
Young GP, Lowe RA: Adverse outcomes of managed care gatekeeping. Acad Emerg Med 4:1129-1136, 1997.
This structured review examined case reports from 1994 to 1995 with possible adverse outcomes related to managed care gatekeeping. Of 29 reports representing ED payment denial, 14% of patients experienced adverse outcomes, 14% more were placed at increased risk, and 72% were considered near misses.
Young LR, et al: Adverse drug reactions: a review for healthcare practitioners. Am J Managed Care 3:1884-1906, 1997.
Reviews the definitions of ADRs; explores the epidemiology and cost issues; identifies classification systems; briefly reviews steps in evaluation and management of ADRs; and describes the impact ADRs have on the patient as well as the health care organization.