last updated 2/11/2000

Hirsch KA, Wallace DT. Software facilitation of root-cause analysis in healthcare organizations.

J Healthcare Risk Manage. 2000;20(Winter):32-35.

Refs:0

Code: ADM

Input date: 01/13/2000

US General Accounting Office. Adverse Drug Events: The Magnitude of Health Risk is Uncertain Because of Limited Incidence Data. Washington, DC: US General Accounting Office. 2000. HEHS-00-21

Refs: 96

Code: MED; REPR

Input date: 02/07/2000

_____. A conversation on medical injury: Lucian L. Leape MD, David D. Swankin JD and Mark R. Yessain PhD.

Pub Health Reps. 1999;114:302-317.

A conversation between a physician, an attorney, and a political scientist is summarized. The different philosophies of each profession are represented as the discussion works to bring the issue of medical injury to a commonality from which to work toward the reduction of its incidence.

Refs:5

Code: ADM; GEN

Input date: 10/21/1999

_____. Addressing health care errors under Medicare. In: Report to Congress: Selected Medicare Issues. June 1999;Medicare Payment Advisory Commission. 37-55.

Refs:41

Code: ADM; GEN

Input date: 10/21/1999

____. First Do No Harm: A Practical Guide to Medication Safety and JCAHO Compliance. Marblehead, MA: Opus Communications, Inc. 1999. ISBN 1-57839-035-4.

Code: MED

Input date: 02/02/1999

______. Optimizing the Medication Use Process: Opportunities for Pharmacy Leadership. Bethesda, MD. American Society of Health-System Pharmacists. 1999.

Code: MED

Input date: 01/22/2000

_____. Safety checks for chemotherapy and immunotherapy. Health Care Advisory Board Fact Brief. 1999;13.

Refs:0

Code: ADM; MED

Input date: 06/16/1999

Alapati SV, Mihas AA. When to suspect ischemic colitis-why is this condition so often missed or misdiagnosed? Postgrad Med. 1999;105:177-180, 183-184, 187.

Refs:10

Code: GEN

Input date: 06/02/1999

Alibhai SMH, Han RK, Nagile G. Medication education of acutely hospitalized older patients. J Gen Intern Med.

1999;14:610-615.

The results of this study indicate that even though patients perceive the education they receive from their physician or pharmacist to be satisfactory, many patients still make errors when they take their medications. On the other hand, the clinicians surveyed identified many barriers to providing adequate education to patients about their medicines, most notably a lack of time.

Refs:41

Code: MED; REL

Input date: 01/22/2000

American Society of Health-Systems Pharmacists. Survey of Top Patient Concerns. Bethesda, MD. American Society of Health-Systems Pharmacists. 1999.

A study finding that 61% of its participants reported that "They were very concerned about getting the wrong medication" is summarized.

Refs:0

Code: MED; REL

Input date: 01/22/2000

Arthur Andersen, American Hospital Association. National Hospital Quality Improvement Survey. Arthur Andersen Healthcare Knowledge Leadership Series. 1999;3.

Refs:0

Code: ADM

Input date: 06/28/1999

Aya AGM, Mangin R, Robert C, Ferrer JM, Eledjam JJ. Increased risk of unintentional dural puncture in night-time obstetric epidural anesthesia. Can J Anesth. 1999;46:665-669.

Human factors such as fatigue, sleep deprivation or task interruption are cited here as factors that increase incidence of iatrogenic injury.

Refs:15

Code: ANE; ERG

Input date: 01/22/2000

Baker CL. The quality of medical textbooks: Bladder cancer diagnosis. J Urol. 1999;161:223-229.

Refs:33

Code: DEC; GEN

Input date: 04/13/1999

Ballantyne FC, Neilly JB. Caution is needed in point-of-care monitoring of oxygen therapy in chronic obstructive pulmonary disease. Ann Clin Biochem. 1999;36:109-111.

Refs:10

Code: GEN

Input date: 05/11/1999

Although developed from the aviation point of view, the basic process outlined here for implementing an accident investigation is applicable. Defining what events are reported, how are incidents reported and/or discovered, how an incident is investigated and reported, and how those reports are coordinated all play an important role in the effective implementation of an investigation protocol, whatever environment it is utilized in.

Refs:0

Code: ADM; REPR

Input date: 10/21/1999

Bates DW, Teich JM, Lee J et al. The impact of computerized physician order entry on medication error prevention.

JAMIA. 1999;6:313-21.

Refs:23

Code: ADM; MED

Input date: 07/30/1999

Refs:111

Code: ERG; SUR

Input date: 10/21/1999

Berlin L. Admitting mistakes. Am J Roentgenol. 1999;172:879-884.

Refs:16

Code: ADM; REL

Input date: 05/21/1999

Berwick DM, Leape LL. Reducing errors in medicine: It is time to take this more seriously. BMJ. 1999;319:136-137.

The success of safety awareness and management in aviation presents an interesting model for medicine. Activity toward applying this model officially in the US has begun to be implemented. Australia, Israel, and the UK have produced studies that support a need for increased organized activity in this arena, but increase organized awareness of the issue and the approached hearlded in aviation has yet to be generated universally. This situation sets the stage for an international "call for papers" in

patient safety.

Refs:7

Code: GEN

Input date: 10/21/1999

Bier VM, Haimes YY, Lambert JH, Matalas NC, Zimmerman R. A survey of approaches for assessing and managing the risk of extremes. Risk Analysis. 1999;19:83-94.

Refs:76

Code: DEC

Input date: 06/15/1999

Blair E. Behavior-based safety: Myths, magic and reality. Prof Safety. 1999;44:25-29.

Refs:22

Code: ERG

Input date: 01/22/2000

Bogardus ST, Holmboe E, Jekel JF. Perils, pitfalls, and possiblities in talking about medical risk. JAMA. 1999;281:1027-1041.

Refs:37

Code: ADM

Input date: 01/06/2000

Bohmer R, Winslow A. The Dana-Farber Cancer Institute. HBS Case #699-025. Harvard Business School. 1999.

Refs:0

Code: ADM; MED

Input date: 10/21/1999

Bonvoglia A. My surgeon make a terrifying error. Redbook. 1999;1113-1114, 1116 et al.

Refs:0

Code: REL; SUR

Input date: 10/21/1999

Bordage G. Why did I miss the diagnosis? Some cognitive explanations and educational implications.

Acad Med. 1999;74:S138-S143.

Refs:73

Code: GEN

Input date: 01/13/2000

Brazeau C. Disclosing the truth about a medical error. Am Fam Physician. 1999;60:1013-1014.

Refs:6

Code: MED; REL

Input date: 01/22/2000

Brock-Utne JG. Near Misses in Pediatric Anesthesia. Woburn, MA: Butterworth Heinmann. 1999. ISBN 0-75067-018-5.

Code: ANE

Input date: 02/05/1999

Broderick-Cantwell JJ. Case study: Accidental clonidine patch overdose in attention-deficit/hyperactivity disorder patients.

J Am Acad Child Adolesc Psychiatry. 1999;38:95-98.

Refs:16

Code: MED

Input date: 04/22/1999

Brodsky JB. What intraoperative monitoring makes sense? Chest. 1999;115(5 suppl):101S-105S.

Refs:20

Code: ANE; DEC

Input date: 06/15/1999

Buerhaus PI. Lucian Leape on the causes and prevention of errors and adverse events in health care. Image: Jnl Nurs Schol. 1999;31:281-286.

Refs:12

Code: ERG; GEN

Input date: 11/16/1999

Caldwell JL. Managing sleep for night shifts requires personal strategies. Hum Factors Aviation Med. 1999;46:1-12.

Refs:29

Code: ERG

Input date: 01/22/2000

Calvert RT. Clinical pharmacy - A hospital perspective. Br J Clin Pharmacol. 1999;47:231-238.

Refs:47

Code: ADM; MED

Input date: 05/21/1999

Casarett D, Helms C. Systems errors versus physicians' errors: Finding the balance in medical education.

Acad Med. 1999;74:19-22.

This paper presents the results of a survey exploring the effect iatrogenic incidents have on decision making in critical care situations--particularly whether or not to resuscitate. The physicians surveyed believed that they had a stronger obligation to treat when an illness is iatrogenic in nature, and that do-not-resuscitate orders (DNRs) would not necessarily apply if it was their care that caused the cardiac arrest. Other reasons for resuscitation include fear of litigation, and the belief that patients probably did not take into account the possibility of an iatrogenic cardiac arrest when they prepared their DNR order.

Refs:22

Code: ADM; ERG

Input date: 03/16/1999

Casarett DJ, Stocking CB, Siegler M. Would physicians override a do-not-resuscitate order when a cardiac arrest is iatrogenic.

J Gen Intern Med. 1999;14:35-38.

Refs:21

Code: DEC; GEN

Input date: 03/16/1999

Cheney FW, Domino KB, Caplan RA, Posner KL. Nerve injury associated with anesthesia--A closed claims analysis. Anesthesiology. 1999;90:1062-1069.

Refs:14

Code: ANE; GEN

Input date: 05/21/1999

Chiodo GT, Tolle SW, Critchlow C. Disclosure of mistakes. Gen Dent. 1999;47:24-28.

Refs:12

Code: ADM, REL

Input date: 07/06/1999

Chung F, Mezei G, Tong T. Adverse events in ambulatory surgery. A comparison between elderly and younger patients.

Can J Anesth. 1999;46:309-321.

Refs:21

Code: ANE; SUR

Input date: 10/20/1999

Clark RB, Graham JD, Williamson JA. Towards system-wide strategies for reducing adverse drug events. J Qual Clin Prac. 1999;19:37-40.

Refs:2

Code: ERG; MED

Input date: 05/28/1999

Cohen JR. Advising clients to apologize. South Cal Law Rev. 1999;72:1009-1069.

Refs:170

Code: ADM; REL

Input date: 01/22/2000

Cohen JS. Ways to minimize adverse drug reactions. Postgrad Med. 1999;106:163-172.

This editorial maintains the author's belief that by relying on manufacturer-recommended doses, physicians are attempting to tailor the patient to fit the drug, resulting in dose-related side effects, rather than addressing the distinct needs of each patient.

Refs:29

Code: MED

Input date: 01/22/2000

Cohen MR (ed). Medication Errors. Washington, DC. American Pharmaceutical Association. 1999. ISBN 0-91733-089-7.

Code: CORE, MED

Input date: 04/30/1999

Coleman IC. Medication errors: Picking up the pieces. Drug Top. 1999;143/6:83-92.

Refs:0

Code: MED

Input date: 05/27/1999

Colodny L, Spillane J. Toward increased reporting of adverse drug reactions. Hosp Pharm. 1999;34:1179-1185.

Refs:18

Code: MED; REPR

Input date: 01/20/2000

Refs:0

Code: ADM; MED

Input date: 03/12/1999

The authors reviewed a 25-year span of the literature on iatrogenic incidents. Historical comparisons on what may have altered the incidences, consequences and causes over that time period were drawn. The resulting numbers were then applied to a review of current records to establish trends. They concluded that even with advancements in technology meant to enhance medical care, iatrogenic disease is a persistent problem that has a negative impact on care and the cost of medicine. A distinction between ‘adverse event’ and ‘preventable iatrogenic event’ was made in this study and definitions were provided

Refs:51

Code: GEN; ICU

Input date: 01/08/1999

Davis NM. Drug names that look and sound alike. Hosp Pharm. 1999;34:1160-1174.

Refs:0

Code: ADM; MED

Input date: 01/20/2000

Dean BS, Barber ND. A validated, reliable method of scoring the severity of medication errors. Am J Health-Syst Pharm. 1999;56:57-62.

A study to develop a reliable, validated method of scoring medication errors based on the potential of patient outcomes, is presented. The objectives were to ascertain the minimum number of judges needed to produce reliable scores, to determine whether or not the profession of the judges (in this case, physicians, nurses and pharmacists), had an effect on the scores they assigned, and to test the validity of the scoring process when the outcome is unknown. The authors concluded that 1) four judges were required; 2) that a mix of professions represented on the scoring team would result in balanced assessments reproducible from any other set individuals from the same set of professions; and 3) that a valid scoring method can be derived without knowledge of patient outcomes.

Refs:37

Code: MED; REPR

Input date: 04/08/1999

Delgado-Rodriguez M, Gomez-Ortega A, Llorca J, Lecuona M, Dierssen T, Sillero-Arenas M, et al. Nosocomial infection, indices of intrinsic infection risk, and in-hospital mortality in general surgery. J Hosp Infect. 1999;41:203-211.

Refs:29

Code: SUR

Input date: 04/28/1999

DeSilva RA. Decision making by cardiac patients: Implications for risk management. Am J Cardiol. 1999;83 (4A sp iss):10B-14B.

Refs:17

Code: DEC; REL

Input date: 04/28/1999

Devitt JH, Rapanos T, Kurrek M, Cohen MM, Shaw M. The anesthetic record: Accuracy and completeness. Can J Anaesth. 1999;46:122-128.

Refs:13

Code: ADM; ANE

Input date: 04/13/1999

Doege TC. Eshewing accidents. JAMA. 1999;282:427.

Refs:6

Code: ADM; GEN

Input date: 01/22/2000

Doldi SB, Marinoni M, Mozzi E, Longoni F, Zappa MA. Iatrogenic injury in videolaproscopic cholecystectomy: Difficult surgical correction biliary tract. Hepato Gatroenterology. 1999;46:1631-1633.

A clinical report presenting two case studies of iatrogenic injury. It concludes that this laproscopic procedure should be converted to an open one if the surgeons involved are not well versed in this method.

Refs:8

Code: SUR

Input date: 01/22/2000

Domino KB, Posner KL, Caplan RA, Cheney FW. Awareness during anesthesia--A closed claims analysis.

Anesthesiology. 1999;90:1053-1061.

Refs:33

Code: ANE; REL

Input date: 05/21/1999

Dubios RW. Pharmacoeconomic decision making: A new type of medication error. West J Med. 1999;171:162-163.

Refs:0

Code: ADM; MED

Input date: 01/22/2000

Duke GJ, Morley PT, Cooper DJ, McDermott FT. Management of severe trauma in intensive care units and surgical wards.

Med J Aust. 1999;170:416-419.

Refs:19

Code: ICU; SUR

Input date: 06/15/1999

Edbril SD, Lagasse RS. Relationship between malpractice litigation and human errors. Anesthesiology. 1999;91:848-855.

Refs:25

Code: ADM; ERG

Input date: 01/20/2000

Edmondson A. Psychological safety and learning behavior in work teams. Adm Sci Q. 1999;44:350-383.

Refs:52

Code: ADM; ERG

Input date: 10/21/1999

Edmondson AC, Bohmer RMJ, Pisano GP. Learning New Technologies and Interpersonal Routines in Operating Room Teams: The Case of Minimally Invasive Surgery. Division of Research Working Paper: Harvard Business School. 1999.

Refs:17

Code: ERG; SUR

Input date: 10/21/1999

Eland IA, Belton KJ, Van Grootheest AC, Meiners AP, Rawlins MD, Stricker BH CH. Attitudinal survey of voluntary reporting of adverse drug reactions. J Clin Pharmacol. 1999;48:623-627.

Refs:7

Code: MED; REPR

Input date: 01/22/2000

Refs:75

Code: GEN

Input date: 02/10/1999

Flaatten H, Hevroy O. Errors in the intensive care unit: experiences with an anonymous registration. Acta Anaesthesiol Scand. 1999;43:614-617.

Refs:7

Code: GEN; ICU

Input date: 07/30/1999

Flaherty GN. Analysing potential harm in Australian general practice: An incident-monitoring study. Med J Aust. 1999;170:287.

Refs:6

Code: REPR

Input date: 06/02/1999

Fleischer L. From pill-counting to patient care: Pharmacists standard of care in negligence law. Fordham L Rev. 1999;68:165-187.

Part I of this article describes society's traditional view of the pharmacist as primarily a technician. Part II examines the standard of care applied to other types of professionals in malpractice suits. Part III argues that courts have been reluctant to expand the scope of pharmacists' responsibilities and thus their liability toward customers. The author concludes that by treating pharmacists as professionals for purposes of negligence suits, courts better serve the interests of both potential plaintiffs and the pharmaceutical industry.

Refs:183

Code: ADM; MED

Input date: 01/22/2000

Fletcher DR, Hobbs MST, Tan P, Valinsky LJ, Hockey RL, Pikora TJ, et al. Complications of cholecystectomy: Risks

of the laparascopic approach and protective effects of operative cholangiography--a population-based study.

Ann Surg. 1999;229:449-457.

Refs:30

Code: GEN; SUR

Input date: 05/21/1999

Flynn EA, Barker KN, Gibson JT, Pearson RE, Berger BA, Smith LA. Impact of interruptions and distractions on dispensing errors in a ambulatory care pharmacy. Am J Health-Syst Pharm. 1999;56:1319-25.

Refs:30

Code: ADM; MED

Input date: 07/30/1999

Fried SM. Bitter Pills: Inside the Hazardous World of Legal Drugs. New York, NY: Bantam Doubleday. 1999.

ISBN 0-55337-852-X.

Code: ADM; MED

Input date: 11/22/1999

Fuller SS, Ketchell DS, Tarczy-Hornoch P, Masuda D. Integrating knowledge resources at the point of care: Opportunities for librarians. Bull Med Lib Assoc. 1999;87:393-403.

Refs:37

Code: ADM

Input date: 01/22/2000

Gawande A. When doctors make mistakes. New Yorker. Feb1, 1999;40-55.

This article represents a resident’s personal account of a mistake made while attending to a trauma case. With this event, the author sets the stage to discuss error in a systems light and shares the feelings physicians have about error. He provides an introduction to the world of medicine and mistakes, his reasoning why malpractice suits are not the answer to reducing error and what impact the inability to openly discuss error has on the people and organizations involved. The article also presents the views of experts who have been working in the field of patient safety from a variety of approaches, highlighting the work of the anesthesiologist community.

Refs:0

Code: ADM; REL

Input date: 02/10/1999

Gawande AA, Thomas EJ, Zinner MJ, Brennan TA. The incidence and nature of surgical adverse events in Colorado and

Utah in 1992. Surgery. 1999;126:66-75.

Refs:55

Code: CORE; SUR

Input date: 01/20/2000

Gerlin A. Medical mistakes: a four part series. Philadelphia Inquirer. Sept 13-17, 1999.

This series frames the multifaceted nature of error in medicine by outlining events at the Medical College of Philadelphia hospitals. Several leaders in the field of patient safety are quoted.

Refs:0

Code: GEN

Input date: 01/22/2000

Gholami K, Shalviri G. Factors associated with preventability, predictability and severity of adverse drug reactions.

Ann Pharmocother. 1999;33/2:236-240.

A randomized study was used to determine the factors pertaining to and the rates of preventability, predictability and severity of ADRs in an Iranian tertiary care hospital. A probability scale, severity assessment scale, and set of criteria to determine the preventability of an ADR were employed to assess the sample from the hospital. It was found that preventable ADRs were more severe, increased with the patient’s age, and resulted in longer hospitalization than nonpreventable ADRs. The authors conclude that ADRs exist in Iran as they do in other parts of the world, and that a national program should be convened in this country to collect and report incidents of ADRs.

Refs:17

Code: MED

Input date: 04/22/1999

Golz G, Fitchett L. Nurses' perspecitve on a serious adverse drug event. Am J Health-Syst Pharm. 1999;56:904-907.

Refs:1

Code: MED; REL

Input date: 01/11/2000

Gosbee JW. Human factors engineering is the basis for a practical error-in-medicine curriculum. 1999.

Refs:41

Code: ERG; GEN

Input date: 01/13/2000

Greely HT. Do physicians have a duty to disclose mistakes? West J Med. 1999;171:82-83.

Refs:2

Code: GEN; REL

Input date: 01/22/2000

Green J. Risk and Misfortune: A Social Construction of Accidents. London, UK: University of London Press. 1997.

ISBN 1-85728-561-1.

Code: ADM; ERG

Input date: 11/18/1999

Greene J. From whodunit to what happened: an amnesty on errors? Hosp Health Networks. 1999;73:50-54.

Refs:0

Code: ADM; GEN

Input date: 05/28/1999

Grossman E. God's work. Amer Spectator. Feb 1999:1-5.

Refs:0

Code: ADM; GEN

Input date: 04/08/1999

Guglielmo BJ, Luber AD, Corelli RL, Flaherty JF. Prevention of adverse events in hospitalized patients using an antimicrobial review program. West J Med. 1999;171:159-162.

Refs:35

Code: ADM; GEN

Input date: 01/22/2000

Hammitt JK, Graham JD. Willingness to pay for health protection: Inadequate sensitivity to probability.

J Risk Uncertainty. 1999;3:33-62.

Refs:77

Code: ADM; REL

Input date: 10/21/1999

Hasagawa GR. Responsibility for medication errors. Am J Heath Syst Pharm. 1999;56:215.

Refs:1

Code: ADM; MED

Input date: 01/20/2000

Henry TR, Azuma L, Shaban HM. Learning and process improvement after a sentinel event. Hosp Pharm. 1999;34:839-844.

Refs:4

Code: ADM; MED

Input date: 07/30/1999

Hillman KM. Recognising and preventing serious in-hospital events. Med J Aust. 1999;171:8-9.

Refs:10

Code: GEN; REPR

Input date: 01/22/2000

Hingorani M, Wong T, Vafidis G. Patients' and doctors' attitudes to amount of information given after unintended injury during treatment: cross sectional, questionnaire survey. BMJ. 1999;318:640-641.

Refs:5

Code: GEN; REL

Input date: 05/28/1999

Hingorani M, Wong T, Vafidis G. Attitudes after unintended injury during treatment: A survey of doctors and patients.

West J Med. 1999;171:81-82.

Refs:5

Code: GEN; REL

Input date: 01/22/2000

Hofgartner WT, Tait JF. Frequency of problems during clinical molecular-genetic testing. Am J Clin Pathol. 1999;112:14-21.

Refs:16

Code: GEN; LAB

Input date: 07/30/1999

Hopkins A. For whom does safety pay? The case of major accidents. Safety Sci. 1999;32:143-153.

This article suggests that, although it may be true that ‘safety pays’ in the abstract sense, that this is irrelevant unless it can be illustrated effectively to the appropriate decision makers. All too often it is not. This article draws its conclusions from industrial accidents that may provide insight for health care applications.

Refs:15

Code: ADM; ERG

Input date: 01/22/2000

Horton R. The uses of error. Lancet. 1999;353:422-423.

This editorial calls for individuals within the medical profession to change the culture of health care to allow for open discussion of error in order to learn from it. The author presents an error in his practice that brought him to this conclusion, and briefly discusses health care in England and how it supports the cycle of fear that keeps clinicians from learning from error. He highlights fear of litigation, erosion of the public trust in physicians, and the necessity for patient consent to report errors as obstacles to achieving the openness that is needed for real learning to take place.

Refs:3

Code: ADM; GEN

Input date: 04/08/1999

Hunter D, Bains N. Rates of adverse events among hospital admissions and day surgeries in ontario from 1992 to 1997.

Can Med Assoc J. 1999;160:1585-1586.

Refs:8

Code: GEN; SUR

Input date: 06/22/1999

Hutchinson D. Getting to the bottom of a sentinel event. Am J Health-Syst Pharm. 1999;56:2031-2032.

Refs:0

Code: ADM; ERG

Input date: 01/20/2000

Isaksen SF, Jonassen J, Malone DC, Billups SJ, Carter BL, Sintek CD. Estimating risk factors for patients with potential

drug-related problems using electronic pharmacy data. Ann Pharmacother. 1999;33:406-412.

Refs:28

Code: ADM; MED

Input date: 06/11/1999

Refs:10

Code: GEN; REL

Input date: 10/21/1999

Refs:4

Code: ADM; REPR

Input date: 01/13/2000

Johnson RN, Baker JR. Analytical error of home glucose monitors: A comparison of 18 systems.

Ann Clin Biochem. 1999;36:72-79.

Refs:7

Code: ERG

Input date: 05/11/1999

Kikendall JW. Pill esophagitis. J Clin Gastroenterol. 1999;28:298-305.

Refs:39

Code: MED; REL

Input date: 06/15/1999

Kingston M. Breaking the culture of silence to minimize medication errors. 1999. Available at: http://ww1.best4health.org/

Refs:13

Code: ADM; MED

Input date: 01/13/2000

Kingston M. The system is broken. Now who's to blame. 1999. Available at: http://ww1.best4health.org/

Refs:8

Code: ADM; ERG

Input date: 01/13/2000

Kluger MT, Laidlaw T, Khursandi DS. Personality profiles of Australian anaesthetists. Anaesth Intensive Care. 1999;27:282-286.

Refs:16

Code: ANE, REL

Input date: 07/07/1999

Knox GE, Kelley M, Simpson KR, Carrier L, Berry D. Downsizing, reengineering and patient safety: Numbers, newness and resultant risk. J Healthcare Risk Manage. 1999;19(Fall):18-25.

Refs:16

Code: ADM

Input date: 10/21/1999

Knox GE, Simpson KR, Garite TJ. High reliability perinatal units: An approach to the prevention of patient injury and medical malpractice claims. J Healthcare Risk Manage. 1999;19(Spring):24-32.

Refs:23

Code: ADM

Input date: 01/06/2000

This long-awaited report by Institute of Medicine (IOM) of the National Academies lays out a comprehensive strategy for government, industry, consumers, and health providers to reduce medical errors, and it calls on Congress to create a national patient safety center to develop new tools and systems needed to address persistent problems.

Code: ADM; CORE; ERG

Input date: 01/22/2000

Kontogiannis T. User strategies in recovering errors in man-machine systems. Safety Sci. 1999;32:49-68.

Refs:41

Code: ERG; HMI

Input date: 01/06/2000

Kraman SS, Hamm G. Risk management: Extreme honesty may be the best policy. Ann Intern Med. 1999;131:963-967.

Refs:11

Code: ADM; REL

Input date: 01/11/2000

Kronz JD, Westra WH, Epstein JI. Mandatory second opinion surgical pathology at a large referral hospital. Cancer. 1999;86:2426-2435.

Refs:31

Code: LAB; SUR

Input date: 01/11/2000

Lawrence D. Is medical care obsolete? Hosp Pharm. 1999;34:1395-1400.

Refs:9

Code: GEN

Input date: 01/13/2000

Refs:13

Code: ADM; MED

Input date: 07/30/1999

Lerner JS, Tetlock PE. Accounting for the effects of accountability. Psych Bull. 1999;125:255-275.

Refs:191

Code: DEC; REL

Input date: 04/28/1999

Liang BA. Error in medicine: legal impediments to US reform. J Health Polit Policy Law. 1999;24:27-58.

Refs:102

Code: ADM; GEN

Input date: 04/08/1999

Liang BA, Cullen DJ. The legal system and patient safety: charting a divergent course.. Anesthesiology. 1999;91:609-611.

Refs:32

Code: ADM

Input date: 10/21/1999

Linden JV, Schmidt GB. An overview of state efforts to improve transfusion medicine-the New York State model.

Arch Pathol Lab Med. 1999;123:482-485.

Refs:10

Code: ADM; LAB

Input date: 06/22/1999

Lortie M, Rizzo P. The classification of accident data. Safety Sci. 1999;31:31-57.

Refs:50

Code: ERG; REPR

Input date: 05/28/1999

Macklis RM. Hidden perlis of automation and its effect on error reduction. Ambulatory Outreach. 1999;Fall:31-34.

Refs:2

Code: GEN; HMI

Input date: 01/22/2000

MacPherson H. Fatal and adverse events from acupuncture: Allegation, evidence, and the implications.

J Alt Complement Med. 1999;5:47-56.

Refs:35

Code: GEN

Input date: 05/26/1999

Mancini ME. Performance improvement in transfusion medicine: what do nurses need and want? Arch Pathol Lab Med. 1999;123:496-502.

Refs:14

Code: ERG; REL

Input date: 06/22/1999

May J, White GH, Waugh R, Stephen MS, Chaufour X, Yu W, et al. Adverse events after endoluminal repair of abdominal aortic aneurysms: A comparison during two successive periods of time. J Vasc Surg. 1999;29:32-39.

Refs:8

Code: GEN; SUR

Input date: 03/16/1999

McMullin ST, Reichley RM, Watson LA, Steib SA, Frisse ME, Bailey TC. Impact of a web-baes clinical information system on Cisapride drug interactions and patient safety. Arch Intern Med. 1999;159:2077-2082.

Refs:18

Code: ADM; MED

Input date: 01/22/2000

Michalodimitrakis M, Christodoulou P, Tsatsakis AM, Askoxilakis I, Stiakakis I, Mouzas I. Death related to midazolam overdose during endoscopic retrograde cholangiopancreatography. Am J Forensic Med Pathol. 1999;20:93-97.

Refs:19

Code: MED

Input date: 05/21/1999

Miles TA, Lowe J. Are unplanned readmissions to hospitals really preventable? J Qual Clin Pract. 1999;19:211-214.

Refs:4

Code: GEN

Input date: 01/13/2000

Mistry SK, Sorrentino AP. Patient nonadherance: the 100 billion dollar problem. Amer Drugist. 1999;56-62.

Refs:0

Code: ADM; MED

Input date: 10/21/1999

Moore J, Berry D, Knox GE. Dispelling urban myths in healthcare risk management. J Healthcare Risk Manage. 1999;19(Spring):2-10.

Refs:7

Code: ADM; ERG

Input date: 01/11/2000

Morris MR. Preventing med errors. RN. 1999;62:69 et al.

Refs:7

Code: MED

Input date: 01/22/2000

Munter KH, Schenk JF, Thrun F, Tiaden JD, Wenzel E, Muller-Oerlinghausen B. The "Phoenix" ADR database of the Drug commission of the German Medical Profession - A clinically useful approach to optimize evidence-based medicine in Germany. Semin Thromb Hemost. 1999;25:57-64.

Refs:7

Code: ADM; REPR

Input date: 06/02/1999

Murr MM, Gigot JF, Nagorney DM, Harmsen WS, Ilstrup DM, Farnell MB. Long-term results of biliary reconstruction after laparoscopic bile duct injuries. Arch Surg. 1999;134:604-609.

Refs:18

Code: SUR

Input date: 06/22/1999

National Patent Safety Partnership. Preventable adverse drug events: Presented at the National Press Club. May 1999.

Refs:0

Code: MED

Input date: 01/13/2000

Naylor CD. Reporting medical mistakes and misconduct. Can Med Assoc J. 1999;160:1323-1324.

Refs:10

Code: ADM; REPR

Input date: 06/11/1999

Niven K. Accident costs in the NHS. Safety Health Practitioner. 1999;17:34-38.

Refs:0

Code: ADM

Input date: 11/16/1999

Osborne J, Blais K, Hayes JS. Nurses' perceptions--When is it a medication error? J Nurs Adm. 1999;29:33-38.

Refs:16

Code: MED; REL

Input date: 06/02/1999

Panko WB. Clinical care and the factory floor. JAMIA. 1999;6:349-353.

The purpose of this article is to provide the author’s perspective on whether it is likely or feasible that those working in health care will adapt safety lessons learned through the use of information technology in industry. Helpful parallels may be drawn from the conclusions that relate to patient safety issues.

Refs:8

Code: ADM; ERG

Input date: 01/22/2000

Perrow C. Normal Accidents--Living with High Risk Technologies (reprint with new afterword and foreward).

Princeton, NJ: Princeton Univeristy Press. 1999.

ISBN 0-69100-412-9.

Code: CORE; ERG

Input date: 11/22/1999

Perrow C. Organizing to reduce the vulnerabilities of complexity. J Contingencies Crisis Manage. 1999;7:150-155.

Refs:15

Code: ADM; ERG

Input date: 10/21/1999

Perry CL, Chendrasekhar A, Paradise NF, Moorman DW, Timberlake GA. Missed injuries in pediatric trama.

Am Surg. 1999;65:1067-1069.

Refs:4

Code: ICU; PED

Input date: 01/11/2000

Posner KL, Freund PR. Trends in quality of anesthesia care associated with changing staffing patterns, productivity, and concurrency of case supervision in a teaching hospital. Anesthesiology. 1999;91:839-847.

Refs:27

Code: ADM; ANE

Input date: 01/22/2000

Putzrath RM, Wilson JD. Fundamentals of health risk assessment. Use, derivation, validity and limitatinos of safety indices.

Risk Analysis. 1999;19:231-247.

Refs:44

Code: ERG

Input date: 10/20/1999

Radhakrishna S. Syringe labels in anaesthetic induction rooms. Anaesthesia. 1999;54:963-968.

Refs:15

Code: ADM; ANE

Input date: 01/13/2000

Rhodes RS. Quality in surgery: From outcomes to process--and back again. Surgery. 1999;126:76-77.

Refs:7

Code: ADM; SUR

Input date: 01/22/2000

Rigby K, Clark RB, Runciman WB. Adverse events in health care: Setting priorities based on economic evaluation.

J Qual Clin Prac. 1999;19:7-12.

Refs:28

Code: ADM; ERG

Input date: 03/24/1999

Risser DT, Rice MM, Salisbury ML, Simon R, Jay GD, Berns DS for the MedTeams Research Consortium. The potential for improved teamwork to reduce medical errors in the emergency department. Ann Emerg Med. 1999;34:373-383.

A teamwork system drawn from the aviation industry is applied to medical emergency room activites. The focus in the Med Teams project is placed on teaching team work behaviors and skills (eg maintenance of teams as groups and communication within them) to improve coordination and reduce error. Cases over the course of 11 years were drawn and approximately 9 teamwork fractures were indicated percase, resulting in increased costs. Through the review 4 individual team work behvaiors were identified that specifically can reduce error and break error chains in teams.

Refs:25

Code: GEN; REL

Input date: 10/21/1999

Rosen MP, Levine D, Carpenter JM, Frost L, Hulka CA, Western DL, et al. Diagnostic accuracy with US: Remote radiologists' versus on-site radiologists' interpretations. Radiology. 1999;210:733-736.

Refs:5

Code: RAD; REL

Input date: 04/13/1999

Rosenstein AH. Measuring the benefits of clinical decision support: Return on investment. Health Care Manage Rev.

1999;24:32-43.

Refs:26

Code: ADM; DEC

Input date: 06/15/1999

Rosenthal MM, Mulcahy L, Lloyd-Bostock S. Medical Mishaps: Pieces of the Puzzle. Buckingham, UK: Open University Press. 1999. ISBN 0-335-20258-6.

Code: GEN

Input date: 06/18/1999

Ryan KD. Driving fear out of the medication-use process so that improvement can occur. Am J Heath-Syst Pharm.

1999;56:1765-1769.

Refs:7

Code: MED; REL

Input date: 01/22/2000

Sanks RJ. A pharmacy manager's perspective on a serious adverse drug event. Am J Health-Syst Pharm. 1999;56:907-909.

Refs:0

Code: ADM; MED

Input date: 01/11/2000

Scheffler A, Zipperer LA eds. Proceedings of Enhancing Patient Safety and Reducing Medical Errors in Health Care.

Chicago, IL: National Patient Safety Foundation. 1999. ISBN 1-57947-055-6.

Code: GEN

Input date: 07/29/1999

Schiff GD. Computerized prescribing: steps to improve therapy. Hosp Pract. 1999;Aug 15:11-12,17-18.

This editorial describes the LADDER approach to implementing effective prescribing by linking bodies of data together to ensure safety: Laboratory data, Allergy info, Drugs, Disease, Education, and Recommendations and Research.

Refs:10

Code: MED

Input date: 01/22/2000

Schneider PJ. Five worthy aims for pharmacy's clinical leadership to pursue in improving medication use.

Am J Health-Syst Pharm. 1999;56:2549-2552.

Refs:14

Code: ADM; MED

Input date: 01/11/2000

Schneider PJ. Creating an environment for improving the medication-use process. Am J Heath-Syst Pharm. 1999;56:1769-1972.

Refs:10

Code: ADM; MED

Input date: 01/22/2000

Schneider PJ. A review of the safety of intravenous drug delivery systems. Hosp Pharm. 1999;34:1044-1056.

An independent panel of experts report collectively on presentations from a national meeting about a variety of non-electric infusion systems, their relative safety, and their implementation costs.

Refs:31

Code: ERG; HMI

Input date: 01/20/2000

Selbst SM, Fein JA, Osterhoudt K, Ho W. Medication errors in a pediatric emergency department.

Pediatr Emerg Care. 1999;15:1-4.

Refs:15

Code: MED; PED

Input date: 05/11/1999

Sinclair M, Simmons S, Cyna A. Incidents in obstetric anaesthesia and analgesia: An analysis of 5000 AIMS reports.

Anaesth Intensive Care. 1999;27:275-281.

Refs:17

Code: ANE; REPR

Input date: 07/07/1999

Small SD, Wuerz RC, Simon R, Shapiro N, Conn A, Setnik G. Demonstration of high-fidelity simulation team training for emergency medicine. Acad Emerg Med. 1999;6:312-323.

This paper describes an evolving collaborative effort to design, demonstrate and refine a high-fidelity emergency medicine simulation course to improve clinician performance, increase patient safety, and decrease liability.

Refs:48

Code: ERG

Input date: 01/22/2000

Sprague L. Reducing medical error: Can you be as safe in a hospital as you are in a jet?

National Health Policy Forum Issue Brief. 1999;740:1-8.

Refs:14

Code: ERG; GEN

Input date: 01/11/2000

Staron RB, Greenspan R, Miller TT, Bilezikian JP, Shane E, Haramati N. Computerized bone densitometric analysis:

Operator-dependent errors. Radiology. 1999;211:467-470.

Refs:26

Code: ADM; RAD

Input date: 06/02/1999

Stiell IG, Wells GA. Methodologic standards for the development of clinical decision rules in emergency medicine.

Ann Emerg Med. 1999;33:437-447.

Refs:88

Code: ADM; ERG

Input date: 05/21/1999

Stolberg SG. Death by prescription. New York Times. June 3, 4 1999.

Refs:0

Code: ADM; MED

Input date: 01/22/2000

Stone D, Patton B, Heen S.. Abandon blame: Map the contribution system. In: Difficult Conversations: How to Discuss What Matters Most. New York, NY: Viking Press. 1999;58-82.

Refs:0

Code: REL

Input date: 10/20/1999

Refs:8

Code: ERG

Input date: 10/21/1999

Taylor-Adams S, Vincent C, Stanhope N. Applying human factors methods to the investigation and analysis of clinical adverse events. Safety Sci. 1999;31:143-159.

Refs:21

Code: ERG; GEN

Input date: 01/13/2000

Tegeder I, Levy M, Muth-Selbach U, Oelkers R, Neumann F, Dormann H, et al. Retrospective analysis of the frequency

and recognition of adverse drug reactions by means of automatically recorded laboratory signals.

Br J Clin Pharmacol. 1999;47:557-564.

Refs:33

Code: ADM; MED

Input date: 06/11/1999

Thomas EJ, Studdert DM, Newhouse JP, Zbar BIW, Howard KM, Williams EJ et al. Costs of medical injuries in Utah and Colorado. Inquiry. 1999;36:255-264.

Refs:35

Code: ADM; CORE; SUR

Input date: 01/20/2000

Tye L. Patients at risk: a four part series. Boston Globe. March 14-17, 1999.

The four articles in this series include: 1) Families tragedies reveal flaws in medical systems 3/14/99; 2) Mistakes plaguing systems; errors at hospitals can prove deadly 3/15/99; 3) Review system for hospitals is ailing 3/16/99; and 4) Seeking a perscription against mistakes 3/17/99.

Refs:0

Code: ADM; GEN

Input date: 03/24/1999

Umiker W. Organizational culture: The role of management and supervisors. Health Care Supervisor. 1999;17:22-27.

Changing the organizational culture of medicine is one component of reducing error. This article explains the importance of corporate culture, the roadblocks to improving it, and share some examples of how successful managers cope with this challenge.

Refs:8

Code: ADM; ERG

Input date: 01/22/2000

van Puijenbroek EP, Egberts ACG, Meyboom RHB, Leufkens HGM. Signalling possible drug-drug interactions in a

spontaneous reporting system: delay of withdrawal bleeding during concomitant use of oral contraceptives and itraconazole.

Br J Clin Pharmacol. 1999;47:689-693.

Refs:16

Code: MED; REPR

Input date: 07/07/1999

Vincent CA. The human element of adverse events. Med J Aust. 1999;170:404-405.

Refs:11

Code: ERG; GEN

Input date: 01/13/2000

Virginia Board of Pharmacy. Study of the Need to Regulate Pharmacy Technicians. Senate Document No. 9. Oct. 15, 1998. Richmond VA: Commonwealth of Virginia. 1999.

Refs:21

Code: ADM; MED

Input date: 10/21/1999

Walton R, Dovey S, Harvey E, Freemantle N. Computer support for determining drug dose: Systematic review and meta-analysis. BMJ. 1999;318:984-990.

Refs:31

Code: ADM; MED

Input date: 01/11/2000

Wears RL, Leape LL. Human error in emergency medicine. Ann Emerg Med. 1999;34:370-372.

Refs:14

Code: ERG; GEN

Input date: 10/21/1999

Weideman RA, Bernstein, McKinney WP. Pharmacist recognition of potential drug interactions. Am J Health-Syst Pharm. 1999;56:1524-9.

Refs:19

Code: ADM; MED

Input date: 08/17/1999

Weiner M, Gress T, Thiemann DR et al. Constrasting views of physicians and nurses about an inpatient computer-based provider order-entry system. JAMIA. 1999;6:234-244.

Refs:36

Code: ADM; HMI

Input date: 10/21/1999

Refs:42

Code: DEC

Input date: 04/13/1999

Weissman JS, Ayanian JZ, Chasan-Taber S, Sherwood MJ, Roth C, Epstein AM. Hospital readmissions and quality of care.

Med Care. 1999;37:490-501.

Refs:51

Code: ADM; GEN

Input date: 06/11/1999

Refs:17

Code: ADM; LAB

Input date: 10/21/1999

Wilson RM, Harrison BT, Gibberd RW, Hamilton JD. An analysis of the causes of adverse events from the Quality in Australian Health Care Study. Med J Aust. 1999;170:411-415.

Baseline adverse event reports from the 1995 Quality in Health Care Study (QAHCS) by Wilson, Runciman and colleagues [Med J Aust 1995;163:458-71) were reviewed. The goal of this project was to define categories for both the human error affecting care and the solutions put in place to prevent errors from occurring. The authors confirmed through this review that human error in health care could in fact be categorized, and that human error is a prominent cause of patient injury. They call for an emphasis on safer system design is called for. Tasks to be addressed to change the emphasis include the development of policies and protocols related to patient safety and an increase in technological decision making support for practitioners.

Refs:12

Code: ERG; GEN

Input date: 06/15/1999

Woodruff DW. Do no harm? Not always. [The] risks of iatrogenic injury. RN. 1999;62:61et al..

Refs:7

Code: GEN

Input date: 01/22/2000

Wu AW, Cavanaugh TA, McPhee SJ, Lo B, Micco GP. To tell the truth: Ethical and practical issues in disclosing

medical mistakes to patients. Section 4: 1999-2000 Update: Risk Management. 1999.

Refs:31

Code: ADM; REL

Input date: 10/21/1999

Zimmermann R, Linhardt C, Weisbach V, Buscher M, Zingsem J, Eckstein R. An analysis of errors in blood component transfusion records with regard to quality improvement of data acquisition and to the performance of lookback and traceback procedures. Transfusion. 1999;39:351-356.

Refs:17

Code: ADM ; core

Input date: 05/27/1999

____. Annual meeting of the American Society of Anesthesiologists: abstracts in patient safety. Anesthesiology. 1998;89:A1172-A1244.

Refs:0

Code: GEN

Input date: 05/25/1999

_____. Best practices for hospital medication services. Health Care Advisory Board Fact Brief. 1998;12.

Refs:0

Code: ADM; MED

Input date: 06/16/1999

_____. Medication errors. Health Care Advisory Board Fact Brief. 1998;9.

Refs:0

Code: MED

Input date: 06/16/1999

_____. Methodologies to weigh medication errors. Health Care Advisory Board Fact Brief. 1998;10.

Refs:0

Code: ADM; MED

Input date: 06/16/1999

____. Minimizing Medical Product Errors: A Systems Approach. Food and Drug Administration. 1998;1-13.

This executive summary serves as a primer for systems issues in reducing medical mistakes. It is the result of a workshop convened to consider how the FDA should use its regulatory influence to reduce risk to patients from misused therapeutics. A variety of experts participated in the event and were invited to speak. Their comments are summarized here. FDA initiatives in medical device safety, biological products, voluntary and mandatory reporting begin the text, while discussions on operating failure sources, human factors solutions, and failure mode and effect analysis framed the event. Other topics presented include those on the aviation parallels to patient safety, reporting systems in transfusion medicine, crisis resource management, look-alike, sound-alike drugs and error proofing in trademarks.

Refs:0

Code: ERG; GEN

Input date: 10/16/1998

____. Sentinel events: approaches to error reduction and prevention. Jt Comm J Qual Improv. 1998;24:175-186.

Refs:44

Code: ADM; ERG

Input date: 05/27/1999

____. Sentinel events: privilege and improving the quality of care. Conn L Tribune. Sept 21, 1998;News:

Refs:0

Code: ADM; REPR

Input date: 01/11/2000

_____. Sentinel events and JCAHO. Health Care Advisory Board Fact Brief. 1998;12.

Four 200 to 400 bed hospitals served as study sites to explore industry feeling for the Joint Commission on Accreditation of Healthcare Organization’s (JCAHO) sentinel event reporting program implemented in October 1996. Individuals at each hospital were asked about their process for trying to comply with the JCAHO reporting program, who is responsible at their hospital for conducting root cause analysis, the framework for that activity, and if their administrators planned to participate in the reporting program. Due to the conclusions of the report, two of the four hospitals profiled opted to not participate in the program. A brief history of the JCAHO sentinel event program is included.

Refs:0

Code: ERG; GEN

Input date: 06/16/1999

Allen J, Evans A, Foulkes J, et al. Simulated surgery in the summative assessment of general practice training: results of a trial in the Trent and Yorkshire regions. Br J Gen Pract. 1998;48:1219-1223.

Refs:24

Code: ADM; SUR

Input date: 09/28/1998

Allison JJ, Kiefe CI, Cook EF, et al. The association of physician attitudes about uncertainty and risk taking with resource use in a Medicare HMO. Med Decis Making. 1998;18:320-329.

Refs:43

Code: ADM; DEC

Input date: 10/15/1998

American Academy of Pediatrics, Committee on Drugs and Committee on Hospital Care. Prevention of medication errors in the pediatric inpatient setting. Pediatrics. 1998;102:428-430.

This call for action highlights that a majority of medication errors that occur within a pediatric medical/surgical inpatient unit are preventable. Steps to reduce these errors, including hospital-wide policies and actions, medication ordering procedures, prescriber actions, pharmacy actions, and what nurses can do to decrease medication error are outlined.

Refs:11

Code: MED; PED

Input date: 03/18/1999

Refs:5

Code: ADM; CORE; MED

Input date: 07/30/1999

Arnold GJ. Clinical recognition of adverse drug reactions: Obstacles and opportunities for the nursing profession.

J Nurs Care Qual. 1998;13:45-48.

By understanding the obstacles to clinically recognizing ADRs, nurses can play a direct role in the recognition and intervention of adverse drug events. The obstacles defined here include 1) lack of a consistently utilized definition, 2) lack of a clear distinction between adverse effect and side effect, 3) a physicians reluctance to report occurrences, and 4) the lack of precise method of identifying clinical suspicion versus causal relationship in recorded events. Seven strategies specific to the role nurses bring to the fore in combating ADRs concludes this discussion.

Refs:27

Code: MED; REPR

Input date: 01/27/1999

Atkin PA, Stringer RS, Duffy JB, Elion C, Ferraris CS, Misrachi SR, et al. The influence of information provided by patients on the accuracy of medication records. Med J Aust. 1998;169:85-88.

Refs:16

Code: ADM; MED

Input date: 03/11/1999

Babu K, Chang A, Chodock R, Klein M, Kuo E, Rene C, et al. Are surgical residents allowed to make mistakes?

Med Health R I. 1998;81:289-291.

Refs:8

Code: REL; SUR

Input date: 05/27/1999

Baldwin I, Beckman U, Shaw L, et al. Australian incident monitoring study in intensive care: local unit review meetings and report management. Anaesth Intensive Care. 1998;26:294-297.

Refs:5

Code: REPR

Input date: 09/28/1998

Baldwin PJ, Dodd M, Wrate RM. Junior doctors making mistakes. Lancet. 1998;351:804.

Refs:5

Code: GEN

Input date: 09/28/1998

Bartlett EE. Physicians' cognitive errors and their liability consequences. J Healthcare Risk Manage. 1998;18(Fall):62-69.

Refs:10

Code: ADM; DEC

Input date: 02/10/1999

Bates DW. Drugs and adverse reactions: how worried should we be? JAMA. 1998;279:1216-1217.

Refs:12

Code: GEN; MED

Input date: 09/28/1998

Bates DW, Leape LL, Cullen, et al. Effect of computerized physician order entry and a team intervention on prevention of

serious medication errors. JAMA. 1998;280:1311-1316.

An exploration into the use of a computerized order entry system and the employment of a defined clinical team in an

effort to affect the occurrence of serious medication errors in a large tertiary care hospital is presented. Two interventions were evaluated: 1) the ordering stage using a computerized physician order entry (POE) process and 2) the administration and dispensing stages of the medication-use process utilizing a ‘team’ comprised of physicians, nurses and pharmacists. The optimal outcome of the study was for nonintercepted serious medication errors to drop: it did by 50%. There was no difference in outcome if the team was employed in addition to the POE. Conclusions are drawn that outline both the administrative and economic applications of these results.

Refs:29

Code: HMI; MED

Input date: 01/29/1999

Battles JB, Kaplan HS, Van der Schaaf TW, Shea CE. The attributes of medical event-reporting systems. Arch Pathol Lab Med. 1998;122:231-238.

Refs:42

Code: GEN; REPR

Input date: 01/27/1999

Berglund S. Systems failures, human error and health care. Medical Liability Monitor. 1998;1-4.

This special segment to Medical Liability Monitor serves as an overview of the role that human error plays in health care. Definitions of error are discussed, and the three disciplines that combine to study human error--Cognitive Science, Human Factors, and Systems Analysis--are outlined. The article concludes with 7 points that risk managers can take to develop and enhance hospital error prevention programs.

Refs:0

Code: ERG; GEN

Input date: 11/18/1998

Bhasale AL, Miller GC, Reid SE, et al. Analysing potential harm in Australian general practice: An incident-monitoring study. Med J Aust. 1998;169:73-76.

Refs:18

Code: GEN

Input date: 03/11/1999

Billings CE. Some hopes and concerns regarding medical event-reporting systems: Lessons from the NASA safety reporting system. Arch Pathol Lab Med. 1998;122:214-215.

Refs:11

Code: REPR

Input date: 04/06/1999

Blegen MA, Vaughn T. A multisite study of nurse staffing and patient occurrences. Nurs Econ. 1998;16:196 et al.

This study explored whether or not the use of non-licensed assistive personnel within nursing units had an effect on frequency of care incidents that were detrimental to the patient. The types of sentinel events reviewed were medication errors, patient falls, and cardiopulmonary arrests. The authors conclude that the percent of registered nurses (RN) within a unit had a positive effect, but only up to a certain point. After that, effectiveness peaks and protection against medication administration errors due to nursing coverage diminishes. This finding is cause for concern yet the following explanations are submitted: 1) more RNs result in more reporting; 2) RNs serve on more complicated cases thus more opportunity for error is introduced, and 3) units with more RNs ultimately have less staff on hand due to the staffing costs involved. Caution and awareness of these issues is advised when restructuring nursing units.

Refs:35

Code: ADM; MED

Input date: 10/16/1998

Blosser SA, Zimmerman HE, Stauffer JL. Do autopsies of critically ill patients reveal important findings that were clinically undetected? Crit Care Med. 1998;26:1332-1336.

Refs:21

Code: DEC; GEN

Input date: 05/20/1999

Bohmer R. Complextity and error in medicine. HBS Case Study #699-025. Harvard Business School. 1998.

Refs:37

Code: ERG; GEN

Input date: 10/21/1999

Boronow RC, Cavett JR 3rd. When your patient asks: "Doctor, I read there have been serious Pap smear errors. Shouldn't I get one of theose new computer Pap smears?" J Miss State Med Assoc. 1998;39:136-141.

Refs:16

Code: REL

Input date: 05/20/1999

Refs:4

Code: GEN

Input date: 03/18/1999

Bovbjerg RR, Sloan FA. No fault for medical injury: Theory and evidence. U Cinn Law Rev. 1998;67:53-123.

Refs:306

Code: ADM; GEN

Input date: 10/21/1999

Bridger S, Henderson K, Glucksman E, Ellis AJ, Henry JA, Williams R. Deaths from low dose paracetamol poisoning.

Refs:20

Code: MED

Input date: 04/22/1999

Chant DF. Teaching you patients to use it safely. Home Healthc Nurse. 1998;16:439-442.

Refs:8

Code: MED; REL

Input date: 04/08/1999

Chassin MR, Galvin RW and the National Roundtable on Health Care Quality. The urgent need to improve health care quality. JAMA. 1998;280:1000-5.

Refs:41

Code: ADM; CORE; GEN

Input date: 07/30/1999

CIOMS Working Group IV. Benefit-risk Balance for Marketed Drugs: Evaluating Safety Signals. Geneva, Switzerland: Council for International Organizations of Medical Science. 1998. ISBN 9-29036-068-2.

Code: ADM; MED

Input date: 02/05/1999

Cohen MR, Proulz SM, Crawford SY. Survey of hospital systems and common serious medication errors.

J Healthcare Risk Manage. 1998(Winter);18:16-27.

A survey of 156 hospitals was utilized to determine the systems-oriented factors that allow for the highest level of safety regarding medication use and administration. The survey ultimately identified 6 categories that result in one-third of the medication errors: allergies, insulin, heparin, opiates, patient-controlled anesthetic devices, and potassium concentrates. The article concludes that increased effort should be placed on developing methods to manage possible error in these six areas. A summary of the overall causes of error reported in this study is included.

Refs:4

Code: ERG; MED

Input date:

Coiera E, Tombs V. Communication behaviours in a hospital setting: an observational study. BMJ. 1998;316:673-676.

Refs:20

Code: REL

Input date: 09/28/1998

Cook RI, Woods DD, Miller C. A Tale of Two Stories: Contrasting Views of Patient Safety. Chicago, IL:

Report from the 1997 National Patient Safety Foundation’s "Workshop on Assembling the Scientific Basis for Patient Safety Research." This workshop brought together a group of 20 researchers from a variety of disciplines and an equal number of interested health care leaders to explore the technical basis for enhancing patient safety. The event was conducted as a wide-ranging discussion that played off the contrasts between "celebrated" stories of health care injury and less publicized cases of systems failure where a deeper investigation produced a "second story" of systems vulnerability that contributed to failure.

Code: ERG; GEN

Input date: 01/07/1999

Cousins DM. Medication Use: A Systems Approach to Reducing Errors. Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations. 1998. ISBN 0-86688-522-6.

Book review available at http://www.ama-assn.org/med-sci/npsf/lit/bkrev2_2.htm

Code: ERG; MED

Input date: 12/04/1998

Das M, Townsend A, Hasan MY. The views of senior students and young doctors of their training in a skills laboratory.

Med Educ. 1998;32:143-149.

Refs:10

Code: ADM

Input date: 09/28/1998

Dehner LP. On trial: A malignant small cell tumor in a child: Four wrongs do not make a right. Am J Clin Pathol.

1998;109:662-668.

Refs:18

Code: ADM; GEN

Input date: 09/28/1998

Douw CM, Bulstra SK, Vandenbroucke J, et al. Clinical and pathological changes in the knee after accidental chlorhexidine irrigation during arthroscopy. J Bone Joint Surg. 1998;80:437-440.

Refs:15

Code: GEN; SUR

Input date: 09/28/1998

Elad Y, Nelson PJ, Meier DE. Jumping to the wrong conclusion. N Engl J Med. 1998;339:1382-1387.

Refs:27

Code: DEC; GEN

Input date: 03/22/1999

Ernst DJ. Four indefensible phlebotomy errors and how to prevent them. J Healthcare Risk Manage. 1998(Spring);18:41-46.

Refs:10

Code: LAB

Input date: 09/28/1998

Escovitz A, Pathak DS, Schneider PJ, eds. Improving the Quality of the Medication Use Process: Error Prevention and Reducing Adverse Drug Events. Binghamton, NY: Haworth Press. 1998. ISBN 0-78900-458-5.

Book review available at http://www.ama-assn.org/med-sci/npsf/lit/bkrev2_3.htm.

Code: MED

Input date: 12/21/1998

Finkelstein KE. The computer cure. New Republic. Sept 14-21,1998:28-33.

Refs:0

Code: MED

Input date: 11/16/1998

Fishman JA, Rubin RH. Medical progress: infection in organ-transplant recipients. N Engl J Med. 1998;338:1741-1751.

Refs:80

Code: GEN

Input date: 09/28/1998

Fitzgerald WL, Wilson DB. Medication errors: lessons in law. Drug Top. 1998;142:84-93.

Refs:0

Code: ADM; MED

Input date: 09/28/1998

Friedman MH, Connell KJ, Olthoff AJ, Sinacore JM, Bordage G. Medical student errors in making a diagnosis. Acad Med. 1998;73:S19-S21.

Refs:12

Code: DEC; GEN

Input date: 05/20/1999

Gaba DM, Howard SK, Flanagan B, et al. Assessment of clinical performance during simulated crises using both technical and behavioral ratings. Anesthesiology. 1998;89:8-18.

Refs:32

Code: ANE

Input date: 09/28/1998

Gawande, A. No mistake. New Yorker. March 30, 1998:74-81.

An application of subspecialty expertise in medicine resulting in safer outcomes serves as the backdrop for comparisons between physicians and computers in diagnostic situations. The example of Shouldice Hospital, its total emphasis on hernia repair, and how that specialization impacts patients at that hospital is presented. The author muses that with the advent of smarter systems to help mechanize care, the physician will be allowed more time to provide the ‘human’ side of care (ie answer questions, build the patient/physician relationship).

Refs:0

Code: ERG; GEN

Input date: 09/28/1998

Gherardi S, Nicolini D, Odella F. What do you mean by safety? J Contingencies Crisis Manage. 1998;6:202-213.

Safety concepts are explored at a construction firm. Different approaches to safety within this single community, each developed and perpetuated by subsets of workers in that firm, are presented. Understanding the different segments of a community, how they individually approach safety, and then how to feed those differences into the development of an overall safety culture parallels how the variety of health care workers in hospitals can co-exist and collectively contribute to the safety culture and design of a safer organizations.

Refs:47

Code: ADM; ERG

Input date: 01/27/1999

Glavin MPV, Chilingerian JA. Hospital care production and medical errors: organizational responses to improve care.

Curr Top Manage. 1998;3:193-215.

This article illustrates the relevance of clinical work to that of organizational production processes. Parallels presented here serve as a multidisciplinary example of learning from others to minimize medical error. An overview of the issue of medical error, the environment of the hospital and the components therein that contribute to error are discussed. Three approaches to enhancing safety are suggested, and possible solutions applied. An exploration of nuclear aircraft carriers, their organization and culture, and how safety lessons from that environment might be applied by clinicians and hospital management to medicine, is also included.

Refs:20

Code: ERG; GEN

Input date: 05/11/1999

Golden MS. An incident reporting system documented at the point of service. J Healthcare Risk Manage. 1998(Spring);18:18-26.

Refs:4

Code: ADM; REPR

Input date: 09/28/1998

Gosbee J. Communication among health professionals: human factors engineering can help make sense of the chaos.

Refs:11

Code: ERG; REL

Input date: 09/28/1998

Grechenig W, Peicha G, Fellinger M, Seibert FJ, Preidler KW. Wrist arthrography after acute trauma to the distal radius: diagnostic accuracy, technique, and sources of diagnostic errors. Invest Radiol. 1998;33:273-278.

Refs:26

Code: DEC; RAD

Input date: 03/11/1999

Haas D. In memory of Ben. Risk Manag Rep. 1998;25:1-6.

Account of an 1996 incident in Stuart Florida in which a young boy died from a error. The resulting investigation was conducted with rigor, integrity, and compassion for the patient’s family, the practitioners and others involved in this incident. It presents a model for what a trusting approach to an unfortunate tragedy can do to enhance patient safety.

Refs:0

Code: MED; REL

Input date: 08/17/1999

Harrell GJ, Kopps DR. Minimizing patient risk during laparoscopic electrosurgery. AORN J. 1998;67:1194-1205.

Refs:38

Code: SUR

Input date: 09/28/1998

Heckman M, Ajdari SY, Esquivel M, et al. Quality improvement principles in practice: the reduction of umbilical cord blood errors in the labor and delivery suite. J Nurs Care Qual. 1998;12:47.

Refs:5

Code: ADM; GEN

Input date: 02/10/1999

Helmreich RL, Merritt AC. Cutlure at Work in Aviation and Medicine: National, Organizational and Professional Influences. Brookfield, VT; Ashgate. 1998. ISBN 0-29139-853-7.

Code: ERG; REL

Input date: 06/23/1999

Hollnagel E. Cognitive Reliability and Error Analysis Method: CREAM. Oxford, UK: Elsevier Science, Inc. 1998.

Code: ERG; REPR

Input date: 07/31/1998

Hurst J, Nickel K, Hilborne LH. Are physicians' office laboratory results of comparable quality to those produced in other laboratory settings? JAMA. 1998;279:468-471.

This article reports the results of an analysis of 1110 clinical laboratories in California participating in proficiency testing. The physicians’ office laboratories (POLs) performed poorly 3-4 times as often as non-POLs. The authors discuss some of the factors that may have contributed to this discrepancy and the danger of eased regulations on laboratory practice.

Refs:9

Code: LAB

Input date: 09/28/1998

Institute for Safe Medication Practices and the Pediatric Pharmacy Advocacy Group. Draft guidelines for preventing medication errors in pediatrics. J Ped Pharm Pract. 1998;3:189-202.

The special treatment required to protect the pediatric patient population from undue exposure to medical errors brought together the two author groups to shape guidelines for prevention of medication errors. This document outlines factors placing pediatric patients at special risk and presents medication error reduction strategies for consideration and discussion in the following components of the health care delivery: ‘systems’ as an entity; educational system; organized health care; computer systems; manufacturing and regulatory systems; individual clinicians; prescribers; pharmacists; nurses; and patients and their caregivers. A version of these guidelines responding to submitted comments, is forthcoming.

Refs:38

Code: MED; PED

Input date: 03/24/1999

Jha AK, Kuperman GJ, Teich JM, et al. Identifying adverse drug events: development of a computer-based monitor and comparison with chart review and stimulated voluntary report. JAMIA. 1998;5:305-314.

Refs:25

Code: MED; REPR

Input date: 10/22/1998

Kapur PA, Steadman RH. Patient simulator competency testing: ready for takeoff? Anesth Analg. 1998;86:1157-1159.

Refs:4

Code: DEC

Input date: 09/28/1998

Keulemans YC, Bergman JJ, Wit LTD, Rauws EA, Huibregtse K, Tytgat GN, et al. Improvement in the management of bile duct injuries? J Am Coll Surg. 1998;187:246-254.

Refs:29

Code: SUR

Input date: 03/18/1999

Klein G. Sources of Power: How People Make Decisions. Cambridge, MA: MIT Press. 1998. ISBN: 0-26211-227-2

Book review available at http://www.ama-assn.org/med-sci/npsf/lit/bkrev6.htm

Code: ADM

Input date: 10/02/1998

Kolbe J, Vamos M, Fergusson W, Elkind G. Determinants of management errors in acute severe asthma. Thorax. 1998;53:14-20.

An exploration into the culmination of serious management errors concerning acute asthma was undertaken. The results show that most management errors were made by patients and that socioeconomic and psychological factors frequently had a role. These conclusions support the theory that many acute asthma attacks are preventable, while presenting the need for a way to help patients to change their ineffective health behaviors. A considerable obstacle inherent in this course of action was to address the socioeconomic factors and psychological barriers that negatively affect health behavior choices.

Refs:40

Code: GEN; REL

Input date: 09/28/1998

A three-part, detailed review by a reporter of the events leading up to the crash of the Valujet flight in the Florida Everglades in 1996 is presented here. It draws on other news accounts, the NTSB investigation, and some independent reporting. It offers a rather careful account of the multiple failures that led to the crash, and it offers a sophisticated analysis of how human and machine failures and sharp- and blunt-end actors played a role. It contains a good sociological perspective of the elusive search for error-free technology.

Refs:0

Code: ERG; HMI

Input date: 09/28/1998

Lazarou J, Pomeranz BH, Corey PN. Incidence of adverse drug reactions in hospitalized patients. JAMA. 1998;279:1200-1205.

Based on the analysis of 39 earlier studies of ADRs, 4.6 % of all deaths in the US were related to serious adverse drug reactions. This study has broad implications for patient safety because it excluded human error from the definition of ADR. This article serves as a clarion to continue to study the administration of medications and their side effects on a patient by patient and drug by drug basis.

Refs:59

Code: GEN; MED

Input date: 09/28/1998

Leape LL, Woods DD, Hatlie MJ, Kizer KW, Schroeder SA, Lundberg GD. Promoting patient safety by preventing medical error. JAMA. 1998;280:1444-1447.

Refs:19

Code: GEN

Input date: 12/03/1998

Leech BF, Carter CJ. Falsely elevated INR results due to the sensitivity of a thromboplastin reagent to heparin. Am J Clin Pathol. 1998;109/6:764-768.

Refs:7

Code: MED

Input date: 04/22/1999

Lesar TS. Errors in the use of medication dosage equations. Arch Pediatr Adolesc Med. 1998;152:340-344.

Refs:18

Code: GEN; MED

Input date: 09/28/1998

Liang BA. Patient injury incentives in law. Yale L Policy Rev. 1998;17:1-93.

Refs:419

Code: ADM; GEN

Input date: 01/11/2000

Libuser CB, Roberts K. Risk mitigation through organizational structure. Org Manage Theory. 1998;1-27.

Refs:32

Code: ADM; ERG

Input date: 11/16/1998

Lyles A, Zuckerman IH, DeSipio SM, Fulda T. When warnings are not enough: Primary prevention through drug use review. Health Aff. 1998;17-5:175-183.

Refs:31

Code: ADM; MED

Input date: 04/15/1999

Refs:4

Code: ADM; MED

Input date: 03/22/1999

Macklis RM, Meier T, Weinhous MS. Error rates in clinical radiotherapy. J Clin Oncol. 1998;16:551-556.

Refs:25

Code: RAD

Input date: 09/28/1998

Martin S. What is a good doctor? Patient perspective. Am J Obstet Gynecol. 1998;178:752-754.

Refs:4

Code: REL

Input date: 01/22/2000

Mascini, P. Risky information: social limits to risk management. J Contingencies Crisis Manage. 1998;3:35-44.

Refs:30

Code: ERG; REPR

Input date: 09/28/1998

Meel B. Inadvertent intrathecal administration of potassium chloride during routine spinal anesthesia.

Am J Forensic Med Pathol. 1998;19:255-257.

This case study presents the clinical findings in the death of a patient and her unborn child due to accidental injection of potassium chloride during spinal anesthesia. Suggestions for protections to have in place when using potassium chloride and the broader issue of look-alike drugs are mentioned.

Refs:9

Code: ADM; ANE

Input date: 03/30/1999

Metheny NA, Ignatavicius DD, Frederick P. Detection of improperly positioned feeding tubes.

J Healthcare Risk Manage. 1998(Summer);18:37-48.

Refs:23

Code: GEN

Input date: 10/26/1998

Miller BJ, Cohen JR, Theile DE, et al. Diagnostic failure in clonoscopies for malignant disease. Aust NZ J Surg. 1998;68:331-333.

Refs:11

Code: GEN

Input date: 10/29/1998

Miller MW, Brayman AA, Abramowicz JS. Obstetric ultrasonography: a biophysical consideration of patient safety--The 'rules' have changed. Am J Obstet Gynecol. 1998;179:241-254.

Refs:66

Code: GEN

Input date: 03/22/1999

MMI Companies, Inc. Transforming Insights into Clinical Practice Improvements. Deerfield, IL: MMI Companies, Inc. 1998.

Refs:0

Code: ADM; SUR

Input date: 09/28/1998

Monane M, Matthias DM, Nagle BA, Kelly MA. Improving prescribing patterns for the elderly through an online drug utilization review invervention. JAMA. 1998;280:1249-1252.

Refs:22

Code: ADM; MED

Input date: 10/21/1999

Montalto M. How safe is hospital-in-the-home care? Med J Aust. 1998;168:277-280.

Refs:32

Code: ADM; GEN

Input date: 09/28/1998

Nakleh RE, Zarbo RJ. Amended reports in surgical pathology and implications for diagnostic error detection and avoidance.

Arch Pathol Lab Med. 1998;122:303-309.

The objective of this study was twofold: to determine the rate of amended reports of a predetermined type, and devise methods to improve error detection and therefore minimize the need to revise reports. Four types of errors defined as most critical to patient care were examined: 1) patient misidentification; 2)preliminary diagnostic errors; 3) final diagnostic errors; and 4) other errors that have therapeutic or prognostic importance. Administrating the revision process to minimize confusion, comply with regulations, and implement broad-based changes to impact the wide variety of issues involved, is emphasized.

Refs:16

Code: LAB; REPR

Input date: 09/28/1998

The 17-member council (which includes FDA) has worked on its "Taxonomy of Medication Errors" over a period of three years. The purpose of this taxonomy is to provide a standard language and structure of medication error-related data for use in developing databases analyzing medication error reports.

Code: MED; REPR

Input date: 02/10/1999

Neale G. Reducing risks in gastroenterological practice. Gut. 1998;42:139-142.

Refs:19

Code: DEC; SUR

Input date: 10/22/1998

Nowicki M, Chaku M. Do healthcare managers have an ethical duty to admit mistakes? Healthc Financ Manage. 1998;52:62.

Refs:8

Code: ADM

Input date: 11/18/1998

Nygaard, HA. Falls and psychotropic drug consumption in long-term care residents: is there an obvious association?

Gerontology. 1998;44:46-50.

Refs:19

Code: MED

Input date: 09/28/1998

O'Connell J, Neale JF. HMO's, cost containment, and early offers: new malpractice threats and a proposed reform.

J Contemp Health Law Policy. 1998;14:287-314.

Refs:174

Code: ADM; GEN

Input date: 03/22/1999

Pathak DS, Escovitz A, ed. Assuring the safe use of medications: the drug approval process and improving treatment decisions. Clin Ther. 1998;20(C):C1-C140.

Refs:0

Code: MED

Input date: 03/26/1999

Perantinides PG, Tsarouhas AP, Katzman VS. The medicolegal risks of thermal injury during laparoscopic monopolar electrosurgery. J Healthcare Risk Manage. 1998(Winter);18:47-55.

Refs:16

Code: ADM; SUR

Input date: 10/16/1998

Phillips DP, Christenfeld N, Glynn LM. Increase in US medication-error deaths between 1983-1993. Lancet. 1998;351:1024-1029.

This research letter examines trends in US deaths from medication errors (ME) between 1983 and 1993. ME deaths increased 2.6-fold during this time, almost twice the increase in the number of prescriptions issued during the same interval. Deaths from sedatives, hypnotics, and tranquilizers dropped, but those from non-psychotropic central and autonomic nervous system drugs increased more than 4-fold. The authors suggest that much of this increase may have resulted from the shift from inpatient to outpatient care during the study time period.

Refs:4

Code: MED

Input date: 09/28/1998

Pilpel D, Schor R, Benbassar J. Barriers to acceptance of medical error: the case for a teaching program. Med Educ. 1998;32:3-7.

Refs:34

Code: ADM; REL

Input date: 09/28/1998

Pirmohamed M, Breckenridge AM, Kitteringham NR, Park BK. Fortnightly review: adverse drug reactions.

Refs:39

Code: MED

Input date: 04/22/1999

Postel EA, Pulido JS, Byrnes Ga et al. Long-term follow-up of iatrogenic phototoxicity. Arch Ophthalmol. 1998;116:753-757.

Refs:44

Code: GEN

Input date: 10/21/1999

Rachliniski, JJ. A positive psychological theory of judging in hindsight. U Chicago Law Rev. 1998;65:571-625.

Refs:237

Code: ADM; ERG

Input date: 09/28/1998

Raschke RA, Gollihare B, Wunderlich TA, Guidry JR, Leibowitz AI, Peirce JC et al. A computer alert system to prevent injury from adverse drug events. JAMA. 1998;280:1317-1320.

Refs:33

Code: MED

Input date: 01/29/1999

Rasmussen J. The concept of human error: is it useful for the design of safe systems? Anesthesia & Crit Care. 1998;1-11.

Refs:22

Code: ERG

Input date: 11/16/1998

Rasmussen J. Merging paradigms: Decision making, managing, and cognitive control. In: Flin R, Salas E, Strub ME, Marting L. Decision Making under Stress: Emerging Paradigms and Applications. 1998

Refs:43

Code: ADM; ERG

Input date: 01/22/2000

Reavis C, Sandidge J, Bauer K. Critical thinking's role in perioperative patient safety outcomes. AORN J. 1998;758-771.

Refs:23

Code: DEC

Input date: 01/27/1999

Reed L, Blegen MA, Goode CS. Adverse patient occurrences as a measure of nursing care quality. J Nurs Adm. 1998;28:62-69.

Refs:34

Code: ADM; GEN

Input date: 09/28/1998

Reeves RR, Pinkofsky HB, Stevens L. Medicolegal errors in the ED related to the involuntary confinement of psychiatric patients. Am J Emerg Med. 1998;16:631-633.

Refs:7

Code: ADM; GEN

Input date: 05/20/1999

Rowe C, Koren T, Koren G. Errors by paediatric residents in calculating drug doses. Arch Dis Child. 1998;79:56-58.

Refs:7

Code: MED; PED

Input date: 03/11/1999

Runciman WB, Helps SC, Sexton EJ, Malpass A. A classification for incidents and accidents in the health-care system.

J Qual Clin Prac. 1998;18/3:199-212.

Refs:0

Code: ADM, ERG

Input date: 04/08/1999

Scheuneman JD, van Fan Y, Clyman SG. An investigation of the difficulty of computer-based case simulations.

Med Educ. 1998;32:150-158.

Refs:0

Code: DEC; ERG

Input date: 09/28/1998

Schiff GD, Rucker TD. Computerized prescribing: building the electronic infrastructure for better medication usage.

JAMA. 1998;279:1024-1029.

This is a well-reasoned plea for the widespread utilization of computerized prescribing systems. The authors summarize a number of problems with the current handwritten prescribing system that could be ameliorated by computerization. These include (among others) better drug selection and dosing; reduction of adverse interactions (drug-patient, drug-illness, drug-drug); improved monitoring of adverse events and post-marketing surveillance; and improved coordination among treatment team members. The authors also review the existing barriers to creating such a system and offer suggestions to overcome these barriers.

Refs:110

Code: HMI; MED

Input date: 09/28/1998

Seeger JD, Kong SX, Schumock GT. Drug use insights: characteristics associated with ability to prevent adverse drug reactions in hospitalized patients. Pharmacotherapy. 1998;18:1284-1289.

The authors sought to identify characteristics of preventable adverse drug events (ADRs). A retrospective analysis was performed on patient reports over a span of four years. Both preventable and non preventable incidents were classified. Determining "preventablity" was difficult; therefore providing insight to the wide range of percentages recorded in the literature for preventable ADRs. Classifications of preventable ADRs are included in the article. A subset of ADR reports within a hospital were further analyzed. The study concludes that hospitalized patients are most prone to be affected by preventable ADRs that are either dosage related or are the result of allergic reactions to specific medications.

Refs:16

Code: MED

Input date: 01/27/1999

Sharpe VA, Faden AI. Medical Harm: Historical, Conceptual and Ethical Dimentions of Iatrogenic Illness. Cambridge, MA: Cambridge University Press. 1998. ISBN 0-521-63490-3.

Book review available at http://www.ama-assn.org/med-sci/npsf/lit/bkrev5.htm

Code: GEN

Input date: 10/02/1998

Sheaffer Z, Richardson B, Rosenblatt Z. Early-warning-signals management: a lesson from the Barings Crisis.

J Contingencies Crisis Manage. 1998;3:1-23.

Refs:140

Code: ADM; ERG

Input date: 09/28/1998

Shimp LA. Safety issues in the pharmacologic management of chronic pain in the elderly. Pharmacotherapy. 1998;18:1313-1312.

Refs:74

Code: MED

Input date: 02/10/1999

Simpson CS, Fisher MA, Curtis MJ, et al. Correlation of waiting time with adverse events in patients admitted for nonelective permanent peacemaker implantation. Can J Cardiol. 1998;14:817-821.

Refs:2

Code: ADM; SUR

Input date: 02/23/1998

Smetzer JL, Cohen MR. Lessons from the Denver medication error/criminal negligence case: Look beyond blaming individuals. Hosp Pharm. 1998;33:640-657.

A gripping report of a systems analysis in the case of three Denver nurses criminally charged in the death of a newborn when he was improperly given a toxic intravenous dose of penicillin is the result of this collaborative effort. The analysis, which revealed over 50 latent failures throughout the system caring for the child, had a powerful influence on the jury, which acquited the nurse in the one case that went to trial. The authors properly advise against the reductionistic tendency to focus on the errors of the sharp-end providers. Their narrative of the case shows how easy it is for many tiny slips to accumulate and lead up to a disaster. The account is frightening in terms of the number of failures but paradoxically reassuring that so many things had to go wrong in order for the outcome to be so awful.

Refs:10

Code: ADM; MED

Input date: 09/28/1998

Refs:44

Code: ADM; GEN

Input date: 01/11/2000

Sommers MS. Missed injuries; undiagnosed injuries. Med Econ. 1998;61:28.

Refs:3

Code: ADM; GEN

Input date: 11/18/1998

Sutter TL, Wellman GS, Mott DA, Schommer JC, Sherrin TP. Discrepancies with automated drug storage and distribution cabinets. Am J Health-Syst Pharm. 1998;55:1924-26.

The way in which health care professionals access automated drug storage and distribution cabinets (ADSCs) was examined. The goal was to to determine discrepancies with drug removal from these cabinets. Both single use and multiple use units were explored. The environment within which the ADSC unit was employed was also studied. The study revealed approximately 7% discrepancies, a majority of which involved access to the ADSC without the appropriate documentation from a physician to use the cabinet.

Refs:5

Code: ADM; HMI

Input date: 01/27/1999

Taylor B. Common bile duct injury during laparoscopic cholecystectomy in Ontario: does ICD-9 coding indicate true incidence? Can Med Assoc J. 1998;158:481-485.

Refs:16

Code: ADM; SUR

Input date: 09/28/1998

Trachtenbarg DE. Ten errors to avoid in managing type 2 diabetes. Postgrad Med. 1998;104:35-43.

Refs:19

Code: GEN

Input date: 04/06/1999

van de Steene J, van den Heuvel F, Bel A, et al. Electronic portal imaging with online correction of setup error in thoracic irradiation: clinical evaluation. Int J Radiat Oncol Biol Phys. 1998;40:967-976.

A method of using online correction of set up errors instead of eye-guided evaluation of lung cancer irradiation was explored. Its broad application to other types of cancer and the measurement of its improvement over manual evaluation were also addressed. The online correction system resulted in less systematic and random errors for all patients involved in the study.

Refs:18

Code: HMI; RAD

Input date: 09/28/1998

Vincent C, Taylor-Adams S, Stanhope N. Framework for analyzing risk and safety in clinical medicine. BMJ.

Refs:27

Code: ERG; GEN

Input date: 08/17/1999

A practical catalogue of factors that acerbate medication error and tools to prevent them is presented. Three areas of susceptibility serve as the structure for the article: opportunities during the 1) prescribing of medication 2) the administration of medication; and 3) those inherent in the self-dosing by patients themselves.

Refs:19

Code: DEC; MED

Input date: 09/28/1998

Welch DL. Human factors analysis and design support in medical device development. Biomed Instrum Technol. 1998;32:77-82.

Human factors engineering analysis and design processes for the development of new systems are outlined. A detailed table of considerations to have in mind when designing a new system is provided. This table illustrates some of the processes and thoughts that should be applied and discussed when developing fault-tolerant systems that do not contribute to the human error inherent in patient care.

Refs:0

Code: ERG

Input date: 09/28/1998

Werth B. Damages: One Family’s Legal Struggles in the World of Medicine. New York, NY: Simon & Schuster. 1998.

ISBN 0-68480-769-6.

This book follows the story of a family's personal experience with a medical malpractice claim following a delivery of twins in which one of infants was born stillborn and the other one was born with severe health problems. Werth details the seven-year lawsuit, a family tragedy and illustrates the intersection between medicine and the law. Damages describes the costs of an adverse event on a single family and their struggle with the legal system to seek reparations for the error that occurred. It is fully indexed and includes approximately 80 references on the subjects of reproductive medicine, birth injury and neurologic impairment, medical malpractice and the history of law and medicine.

Code: ADM; GEN

Input date: 07/01/1998

Wilson DG, McArtney RG, Newcombe RG, McArtney RJ, Gracie J, Kirk CR, et al. Medication errors in paediatric practice: insights from a continuous quality improvement approach. Eur J Pediatr. 1998;157:769-774.

Refs:30

Code: MED; PED

Input date: 05/27/1999

Wolfe S. When caregivers endanger patients--part 2: reporting of medical errors. RN. 1998;61:28-35.

Refs:4

Code: REL; REPR

Input date: 01/27/1999

Wood C. The misplace of litigation in medical practice. Aust N Z J Obstet Gynaecol. 1998;38:365-376.

Refs:20

Code: ADM; DEC

Input date: 05/20/1999

Wright P, Jansen C, Wyatt JC. How to limit clinical errors in interpretation of data. Lancet. 1998;352:1539-1543.

Refs:44

Code: ADM; GEN

Input date: 04/08/1999

Zardawi IM, Bennet G, Jain S, Brown M. The role of peer review in internal quality assurance in cytopathology.

Pathology. 1998;30:309-313.

Refs:11

Code: ADM; GEN

Input date: 04/06/1999

____. JCAHO expectations regarding medication errors and adverse drug events.

ASHP Update Qual Improvement. 1997;18:192-9.

Refs:0

Code: ADM; MED

Input date: 08/17/1999

_____. Phlebotomy specimen mislabelings. Health Care Advisory Board Fact Brief. 1997;5.

Refs:0

Code: ADM; LAB

Input date: 06/16/1999

Andrews LB, Stocking C, Krizek T. An alternative strategy for studying adverse events in medical care. Lancet. 1997;349:309-13.

This innovative, prospective study was carried out to identify adverse events in medical care. Ethnographers trained in observational research attended all rounds and teaching conferences for one surgical and two intensive-care units at a University teaching hospital over 9 months, then the adverse event cases were followed up for 2 years post-hospitalization. Risk was roughly proportional to length of hospital stay. Only 1.2% of adverse events led to a legal claim. Causes were designated as individual, interactive, or administrative. Nearly half of the patients experienced an adverse event, and in one-third of those (17.7%) the event was serious.

Refs:16

Code: GEN

Input date: 09/28/1998

Bates DW, Spell N, Cullen DJ et al. The costs of adverse drug events in hospitalized patients. JAMA. 1997;277:307-11.

This article reports on a study of adverse drug events (ADEs) occurring in over 4000 admissions to 2 tertiary-care hospitals during a 6-month period based on reports and chart reviews. There were 190 ADEs, about a third of which were judged preventable. The average ADE added 2.2 days of hospitalization and $3200 in medical expenses; the figures were Substantial efforts to reduce these ADEs are warranted on financial grounds alone. about twice as high for preventable ADEs.

Refs:40

Code: ADM; MED

Input date: 09/28/1998

Baylis F. Errors in medicine: nurturing truthfulness. J Clin Ethics. 1997;8:336-340.

An important part of reducing error in medicine is candid discussion on errors that may occur within the professional ranks, as well as between providers and the patients involved. This article presents both the reasons why physicians may not wish to disclose fully their mistakes and possible solutions for remedying the reluctance to discuss them.

Refs:10

Code: GEN; REL

Input date: 06/22/1999

Belkin L. Who's to blame? It's the wrong question. New York Times Magazine. June 1997;Sec 6:28-33, 44, 50, 63, 66, 70.

This thoughtful Sunday magazine piece examines several well-publicized medical disasters and shows that each case was more complex than the way they were reported in the popular press. In particular, the article highlights how multiple errors in a complex series of steps all had to occur for the final outcome to have transpired. While quite fairly criticizing the health care system for its excessive tolerance of error, the author also describes some of the conceptual and cultural changes and safety movements underway to address this state of affairs.

Refs:0

Code: CORE; GEN; REL

Input date: 09/28/1998

Brodell RT, Helms SE, Krishna Rao I, Bredle DL. Prescription errors: legibility and drug name confusion.

Arch Fam Med. 1997;6:296-98.

This brief report describes three cases of inadvertent drug substitution occurring in the authors’ suburban dermatology practice that were due to physicians’ illegible handwriting. The authors review the literature on legibility and error and offer specific suggestions to reduce the problem. They encourage active participation on the part of patients to help catch errors before they cause adverse events.

Refs:43

Code: ADM, MED

Input date: 09/28/1998

Brown RW. Errors in medicine. J Qual Clin Prac. 1997;17:21-25.

The problem of medical error as outlined in the 1991 Harvard Medical Practice Study and the subsequent 1995 Quality

in Australian Health Care Study is presented from the systems perspective. Applications of methods from the aviation model

of error reduction and the Australian health care system are summarized. Specific examples of Australian programs are presented. This commentary closes with a call for the medical community to embrace research illustrating the effectiveness of the

systems approach.

Refs:16

Code: GEN; ERG

Input date: 01/27/1999

Brown SL, Bogner MS, Permentier CM, Taylor JB. Human error and patient-controlled analgesia pumps. J Intraven Nurs. 1997;20:311-316.

The human factors concept of using near misses and promoting a blame free approach to error reduction is applied to a discussion of patient controlled analgesia pumps (PCAs). Several adverse incidents with PCAs resulting from error and reported to the Food and Drug Adminstration are utilized here as case studies to illustrate how the application of a human factors philosophy to reported error by looking at the design of the devise as a prevention mechanism for error.

Refs:13

Code: ANE; ERG

Input date: 10/26/1998

Calkins DR, Davis RB, Reiley P, Phillips RS, Pineo K, Delblanco TL. Patient-physician communication at hospital discharge and patients' understanding of the post-discharge treatment plan. Arch Intern Med. 1997;157:1026-30.

The results of a survey of physicians and their patients who had recently been discharged from the hospital with pneumonia or a myocardial infarction are reported here. Physicians overestimated the amount of time they spent discussing post-discharge plans, side effects of medications, and resumption of activities when compared to patient reports. This communication gap highlights a potential cause of multiple errors and suggests a focus for preventing those errors.

Refs:19

Code: REL

Input date: 09/28/1998

Refs:0

Code: ADM; MED

Input date: 07/30/1999

Chin TL. Using automation to reduce medication errors. Health Data Manage. 1997.

This article strongly advocates for computer systems to automate many of the steps involved in ordering, transcribing, dispensing, and administering drugs. Since about one-third of adverse drug events are preventable--and at times quite expensive--automated systems could prevent many errors, thus improving patient care and saving institutions money. Errors in ordering, particularly with regard to dosing, drug selection, or drug-drug interactions could be reduced by as much as 85%. Resistance on the part of administrators and practitioners needs to be overcome.

Refs:0

Code: HMI; MED

Input date: 09/28/1998

Classen DC, Pestotnik SL, Evans RS, et al. Adverse drug events in hospitalized patients: excess length of stay, extra costs and attributable mortality. JAMA. 1997;277:301-306.

A nice companion to the 1997 Bates et al JAMA study, this paper reports the experience with adverse drug events (ADEs) in a 3-year period at a single tertiary-care hospital. Patients who experienced ADEs were matched with controls of similar age, gender, DRG, and acuity. ADEs occurred at a rate of 2.43 per 100 admissions and lead to an increased risk of death of 1.88; average additional length of hospital stay of 1.7 days; and average excess cost of $2262.

Refs:40

Code: MED

Input date: 09/28/1998

Collopy BT, O'Hara DA. Reporting of adverse events in hospitals in Victoria 1994-1995. Med J Aust. 1997;167:342-3.

Refs:130

Code: GEN

Input date: 09/28/1998

Connelly DP, Aller RD. Outcomes and informatics. Arch Pathol Lab Med. 1997;121:1176-1182.

Refs:26

Code: ADM

Input date: 09/28/1998

Crane M. How good doctors can avoid bad errors. Med Econ. April 28 1997;74:36-43.

This is an overview of how thinking about error and safety needs to consider factors beyond individual practitioners. The article explains how the medical and legal cultures’ focus on culpability leads to neglecting system, design, and human-machine interface factors when things go wrong. The article offers a long list of practical tips to reduce error generally (simplification, communication, standardization, etc) and medication errors specifically (unit dosing, elimination of look-alikes, protocols, etc).

Refs:0

Code: GEN

Input date: 09/28/1998

Crane M. When a medical mistake becomes a media event. Med Econ. May 27, 1997;74:158-171.

This thoughtful article looks behind the media hoopla surrounding a highly-publicized 1995 case of a surgeon amputating the wrong leg of a patient. The reporter goes over all of the mis-steps that occurred that led to the result, emphasizing that the leg which was removed was also quite diseased and likely to require amputation soon too. This becomes a good case study of the need to think systemically about error rather than going for the obvious conclusion. The article also highlights how the media can distort a situation almost beyond recognition in its need to simplify and find clear heroes and villains.

Refs:0

Code: ADM; MED

Input date: 09/28/1998

Cullen DJ, Sweitzer BJ, Bates DW, Burdick E, Edmondson A, Leape LL. Preventable adverse drug events in hospitalized patients: a comparative study of intensive care and general care units. Crit Care Med. 1997;25:1289-97.

Another report from the Adverse Drug Event (ADE) Prevention Study Group at Harvard, this compares ADEs in 5 intensive care units (ICUs) with 11 general med-surg units. Preventable ADEs occurred at a rate twice as high in ICUs as on general floors, as did potential ADEs. The ADEs were not a function of extremes of workplace environment, however they did seem to be related to the greater number of drugs ordered in ICU patients.

Refs:188

Code: ICU; MED

Input date: 09/28/1998

Dale JC, Renner SW. Wristband errors in small hospitals: a College of American Pathologists' Q-probes study of quality issues in patient indentification. Lab Med. 1997;28:203-209.

Refs:6

Code: ADM; GEN

Input date: 04/08/1999

Davis NM. Drug names that look and sound alike. Hosp Pharm. 1997;32:1558, 1561-1570.

This report looks at the issue of drugs with names that are either similar in sound or appearance to other drugs. This similarity can produce potential errors in medication if drug information is poorly communicated. Methods for reducing this error potential is stated, along with a table that lists the names of various drugs that are similar in sound or appearance.

Refs:0

Code: ADM; MED

Input date: 04/28/1999

de Leval MR. Human factors and surgical outcomes: a Cartesian dream. Lancet. 1997;349:723-725.

Refs:8

Code: ERG; SUR

Input date: 04/22/1999

Dörner D. Logic of Failure: Recognizing and Avoiding Error in Complex Situations. Reading, MA: Addison Wesley. 1997.

ISBN 0-20147-948-6.

Code: ERG

Input date: 09/01/1998

Dunn EB, Wolfe JJ. Medication error classification and avoidance. Hosp Pharm. 1997;32:860-5.

Refs:20

Code: ADM; MED

Input date: 08/17/1999

This is a brief introduction to human factors philosophies and processes and how they can improve patient safety. Diagnostic errors serve as examples for the application of the human factors approach to reducing error in health care. Dr. Leape also touches on the ‘blame and train’ (ie focusing on a person's inadequacy as a way of improving their performance) paradigm of medical education and how that must change in order to make progress.

Refs:0

Code: ERG; GEN

Input date: 09/28/1998

Elson RB, Faughnan, Connelly DP. An industrial process view of information delivery to support clinical decision making implications for systems design and process measures. JAMA. 1997;4:266-278.

Refs:95

Code: DEC; ERG

Input date: 09/28/1998

Feinstein AR, Horwitz RI. Problems in the "evidence" of "evidence-based medicine." Am J Med. 1997;103:529-535.

Refs:32

Code: DEC

Input date: 09/28/1998

Fernandes CMB, Walker R, Price A, Marsden J, Haley L. Root cause analysis of laboratory delays to an emergency department. Emerg Med. 1997;15:735-9.

Refs:11

Code: ERG; LAB

Input date: 09/28/1998

Fischer G, Fetters MD, Munro AP, Goldman EB. Adverse events in primary care identified from a risk-management database.

J Fam Pract. 1997;45:40-46.

Refs:17

Code: GEN; LAB

Input date: 09/28/1998

Fletcher CE. Failure mode and effects analysis: an interdisciplinary way to analyze and reduce medication errors.

JONA. 1997;27:19-26.

Refs:34

Code: ERG; MED

Input date: 09/28/1998

Furrow BR. Managed care organizations and patient injury: rethinking liability. Geo Law Rev. 1997;31:419-509.

Refs:389

Code: ADM

Input date:

Gosbee J. The discovery phase of devise design: a blend of intuition, creativity and science. 1997.

Refs:9

Code: ERG; HMI

Input date: 01/13/2000

Refs:0

Code: GEN; REL

Input date: 09/28/1998

James BC. Every defect a treasure: learning from adverse events in hospitals. Med J Aust. 1997;166:484-487.

Initiatives at Salt Lake City’s LDS Hospital are presented to illustrate the effective use of computerized medical record systems to detect adverse drug events (ADEs). A solid description of two approaches to the use of data collected on ADEs--a judgmental versus a learning system--provides the framework for the initiatives at LDS. Within the course of these LDS projects, a categorization scheme for ADEs was developed, and the ADE rate at the hospital dropped 30%.

Refs:24

Code: ERG; MED

Input date: 04/13/1999

Jeffords JM, Kennedy EM. FDA analysis; GAO study: Some problems overlooked? Improvements needed in the FDA's system for monitoring problems with apporoved devices. Biomedical Market Newsletter. 1997;7:3-29.

Refs:0

Code: GEN

Input date: 03/18/1999

Johnson JA, Bootman JL. Drug-related morbidity and mortality and the economic impact of pharmaceutical care.

Am J Health-Syst Pharm. 1997;54:554-8.

Refs:19

Code: ADM; CORE; MED

Input date: 08/17/1999

Kanter MH. Misinterpretation and misapplication of "p" values in antibody identification: the lack of the value of a "p" value. Transfusion. 1997;37:816-822.

Refs:28

Code: LAB

Input date: 09/28/1998

Kapp MB. Medical error versus malpractice. DePaul J Health Care Law. 1997;1:750-772.

Refs:95

Code: ADM; GEN

Input date: 09/28/1998

Lambert BL. Predicting look-alike and sound-alike medication errors. Am J Health-Syst Pharm. 1997;54:1161-1171.

Refs:41

Code: ADM; MED

Input date: 03/23/1999

Lantos J. Should doctors tell the truth? One physicians prescription for one of medicine's lingering ailments. Chicago Tribune Magazine. May 4 1997;Section 10:13-16, 26.

The author, a pediatrician and medical ethicist at the University of Chicago, begins by confessing that he has made "quite a few mistakes in [his] time." He feels terrible about this, but he knows that his colleagues have all had similar experiences yet they are remarkably reluctant to discuss errors (or their feelings about them) openly. While he generally supports the idea that honesty is a good policy, he gives some examples of how too much disclosure can be harmful or lead to worse outcomes than non-disclosure. This is a highly readable, thought-provoking excerpt from Lantos’ book, Do We Still Need Doctors?

Refs:0

Code: GEN; REL

Input date: 09/28/1998

Leibovici D, Gofrit ON, Heruti RJ, Shapira SC, Shemer J, Stein M. Interhospital patient transfer: a quality improvement indicator for prehospital triage in mass casualities. Am J Emerg Med. 1997;15:341-344.

Refs:8

Code: DEC; GEN

Input date: 04/08/1999

Lesar TS, Briceland L, Stein DS. Factors related to errors in medication prescribing. JAMA. 1997;277:312-317.

Refs:0

Code: MED

Input date: 09/28/1998

Lesar TS, Lomaestro BM, Pohl H. Medication-prescribing errors in a teaching hospital. Arch Intern Med. 1997;157:1569-1576.

The 11,000-plus medication-prescribing errors that were detected and averted by staff pharmacists at a teaching hospital over a 9-year period are reported on here. The absolute number of errors and the error rate (errors per prescription written, per admission, and per patient-day) increased over the study period. Dosing errors accounted for more than half of the errors. Xanthines, antibiotics, and cold/cough medications were the classes most commonly implicated. Because of the error detection program in place at the hospital, none of these errors led to adverse events, but the data analysis offers a good understanding of factors involved in medication errors.

Refs:56

Code: MED

Input date: 09/28/1998

Linn S, Knoller N, Giligan CG, Dreifus U. The sky is the limit: errors in prehospital diagnosis by flight physicians.

Am J Emerg Med. 1997;15:316-320.

This is a report of a survey of 186 trauma cases that underwent airborne evacuations from the site of injury. The diagnoses of the flight physicians were compared to assessments by surgical experts using ACS Advanced Trauma Life Support criteria. Three-quarters of the diagnoses were correctly recorded by the flight physicians, however 10 critical and 56 important diagnoses were missed. The authors describe the feasibility of having made the missed diagnoses and the types that were most commonly overlooked.

Refs:27

Code: GEN

Input date: 09/28/1998

Lowes RL. Made a bonehead mistake? Med Econ. May 12, 1997;74:94-109.

A short article which explains the ethical imperative and the practical reasons for a physician to admit an error and apologize to a patient. The author reassures readers that rather than increase malpractice liability, such an approach may eve reduce it. He also explains how this approach is consonant with almost-universal patient preferences and may help the doctor-patient relationship.

Refs:0

Code: REL

Input date: 09/28/1998

Lyczko EJ. The human factors of medical gas systems; safety of medical gas delivery systems depend on humans.

Heat Piping Air Cond. 1997;69:56 et al.

Refs:0

Code: ERG

Input date: 09/28/1998

Malviya S, Voepel-Lewis T, Tait AR. Adverse events and risk factors associated with the sedation of children by nonanesthesiologists. Anesth Analg. 1997;85:1207-1213.

In response to this hospital’s implementation of sedation guidelines and the organization’s lack of compliance with those guidelines, the records of children who experienced adverse events and outcomes were chosen to serve as the data for this study to determine risks associated with sedation techniques and pediatric patient characteristics. The study team concluded that documentation is a low priority in a busy clinical setting, that the risks for sedating children are therefore underreported, and that children assigned ASA physical status III or IV, or are less than one year old are more apt to experience sedation related adverse events, supporting the need for fully trained personnel to be involved in their monitoring.

Refs:0

Code: ANE; PED

Input date: 09/28/1998

Millenson ML. Demanding Medical Excellence: Doctors and Accountability in the Information Age. Chicago, IL:

University of Chicago Press. 1997. ISBN 0-22652-587-2.

Code: ADM

Input date: 09/01/1998

Morell RC, Eichhorn JH (eds). Patient Safety in Anesthetic Practice. New York, NY: Churchill Livingston. 1997.

ISBN 0-443-07682-0.

Code: ANE

Input date: 01/28/1999

Morello DC, Colon GA, Fredricks S. Patient safety in accredited office surgical facilities. Plast Reconstr Surg.

1997;99:1496-1500.

Here is a little bit of good news for a change on the safety front. The American Association for Accreditation of Ambulatory Surgery Facilities sent a questionnaire to over 400 facilities asking about complications occurring during and after procedures done in their facilities. Over 400,000 operations were included over a 5-year period. Significant complications occurred in fewer than 1 in 200 cases, and there was 1 death per 57,000 cases. The authors conclude that risks in accredited offices for plastic surgery is comparable to that seen in free-standing or outpatient hospital surgical facilities.

Refs:5

Code: SUR

Input date: 09/28/1998

Refs:0

Code: CORE; REL

Input date: 09/28/1998

Nora PF, ed and the Professional Liabilty Committee, American College of Surgeons. Professional Liability Risk Management:

A Manual for Surgeons--2nd ed. Chicago, IL: American College of Surgeons. 1997. ISBN 1-88069-608-8.

Code: ADM; SUR

Input date: 08/17/1999

O'Hara DA, Carson NJ. Reporting of adverse events in hospitals in Victoria 1994-1995. Med J Aust. 1997;166:460-463.

This is a report of the Quality in Australian Health Care Study (QAHCS), a study modeled after the Harvard Medical Practice Study (HMPS). It describes a retrospective analysis of adverse events (AEs) from over 200 acute-care hospitals in Victoria, Australia. AEs were documented in 5% of discharges, with risk increasing with patient age. Over 80% were post-surgical or post-procedure complications, although 19% were adverse drug events and 1.9% were "misadventures" (provider errors).The in-hospital death rate was twice as high for those who experienced AEs. An accompanying editorial calls for attention to these results.

Refs:13

Code: GEN; REPR

Input date: 09/28/1998

Pate-Cornell ME, Lakats LM, Murphy DM, Gaba DM. Anesthesia patient risk: a quantitative approach to organizational factors and risk management options. Risk Analysis. 1997;17:511-523.

This paper explores and assesses both the effects of human and management components on patient risk in anesthesia. Probabilistic Risk Analysis (PRA)is applied to a pilot to define patient risk per operation, to then allow for the probabilities to be linked to the root causes of different accident types. The authors conclude the errors in anesthesia could be reduced through 1) increased supervision of residents, 2) the use of anesthesia monitors in training and in recertification, and 3) regular medical competence examinations for all anesthesiologists.

Refs:40

Code: ANE

Input date: 09/28/1998

This excerpt from Beyond Engineering: A New Way of Thinking About Technology [Oxford University Press, 1997], discusses the research of the high-reliability organization project at the University of California at Berkeley, summarizing the 10-year findings of how certain groups operate complex, hazardous technologies with great safety. Pool discusses the US air traffic control system, nuclear aircraft carriers and the Diablo Canyon nuclear plant as exemplars. He highlights the commitment to safety that permeates the culture of these entities and how communication and active learning are strongly emphasized. He notes that these organizations seem to find a way to shift between centralized (hierarchical) and decentralized (egalitarian, collegial) modes as needed by circumstances. The application of these concepts to the health care environment are of interest to the patient safety movement.

Refs:7

Code: ERG; HMI

Input date: 09/28/1998

Rasmussen J. Risk management in a dynamic society: a modeling problem. Safety Sci. 1997;27:183-213.

Refs:96

Code: ERG

Input date: 11/16/1998

Ray WA, Taylor JA, Meador KG. A randomized trial of a consultation service to reduce falls in nursing homes.

JAMA. 1997;278:557-62.

This study looked at the impact of an intervention program to reduce falls in 7 study and 7 control nursing homes with a combined population of almost 500 residents assessed to be at high risk. The intervention consisted of a structured safety assessment with specific recommendations about ambulation, wheelchair use, psychotropic drug use, and environmental factors. There was a modest improvement shown in the intervention group, with improved outcomes seen when there were more falls and when the safety recommendations were actually carried out.

Refs:41

Code: ADM

Input date: 09/28/1998

Reason J. Managing the Risks of Organizational Accidents. Ashgate, Aldershof, UK. 1997. ISBN 0-84014-104-2.

Code: CORE; ERG

Input date: 09/28/1998

A practical catalogue of factors that acerbate medication error and tools to prevent them is presented. Three areas of susceptibility serve as the structure for the article: opportunities during the 1) prescribing of medication 2) the administration of medication; and 3) those inherent in the self-dosing by patients themselves.

Refs: 0

Code: MED

Input date: 01/25/1999

Savader SJ, Lillemoe MD, Prescott CA. Laproscopic cholecystectomy--related bile duct injuries. Ann Surg. 1997;225:268-273.

Laparoscopic cholecystectomy (LC) has been far easier on most patients and much less expensive than traditional open-abdomen surgery, however, for that small percentage of patients with complications from LC, the toll can be high. This is a report of the costs for 49 patients who had LC-associated bile duct injuries. These patients incurred average hospitalizations of 32 days at a cost of over $50,000 for all care to repair the injury. Two patients died, and biliary intubation as part of treatment averaged 378 days.

Refs:25

Code: ADM; SUR

Input date: 09/28/1998

Code: ERG

Input date: 09/28/1998

Ukens C. Deadly dispensing: an exclusive survey of Rx errors by pharmacists. Drug Top. 1997;100-112.

A report of a nationwide survey of community pharmacists about their experiences with medication errors. The author points out how prevalent these are (by self-report and from studies) and how expensive they can be (with some truly horrific case examples). Practical tips to reduce errors are also presented.

Refs:0

Code: MED

Input date: 09/28/1998

US General Accounting Office. Aviation Safety: Efforts to Implement Flight Operational Quality Assurance Programs. Washington DC: US General Accounting Office. 1997. RCED-98-10.

Code: ERG

Input date: 09/28/1998

US General Accounting Office. Medical Device Reporting:Improvements Needed in FDA's System for Monitoring Problems with Approved Devices. Washington DC: US General Accounting Office. 1997. HEHS-97-21.

Code: ERG

Input date: 09/28/1998

Veltman LL. Managing bad results. Group Pract J. 1997;46:26-32.

Here is brief and practical advice from a physician with insurance experience in risk management and medical liability. He emphasizes the need for individual physicians and groups to anticipate that bad results will occur from time to time and to have protocols in place. The keys to helping patients when there are adverse outcomes include good patient-physician communications, adequate informed consent, and thorough documentation. Attention must be paid to the patient both before and after the event, the organization’s response, and adequate assessment of system failures and lessons that should have been learned.

Refs:7

Code: ADM; REL

Input date: 09/28/1998

Victoroff MS. The right intentions: errors and accountability. J Fam Pract. 1997;45:38-39.

Refs:1

Code: ADM; GEN

Input date: 03/23/1999

Vincent C, Knox E. Clinical risk modification, quality, and patient safety: interrelationships, problems, and future potential.

Best Pract Benchmarking Healthc. 1997;2:221-226.

Refs:32

Code: ADM; GEN

Input date: 09/28/1998

Wagner JT, Meier C, Higdon T. A perspective from clinical and business ethics on adverse events in hospitalized patients.

J Fla Med Assoc. 1997;84:502-505.

Refs:10

Code: ADM

Input date: 09/28/1998

Wilson RM, Harrison BT. Are we committed to improving the safety of health care? Med J Aust. 1997;166:442-3.

Refs:0

Code: ADM

Input date: 09/28/1998

Wu AW, Cavanaugh TA, McPhee SJ. To tell the truth: ethical and practical issues in disclosing medical mistakes to patients.

J Gen Intern Med. 1997;12:770-775.

This is another paper urging that physicians disclose to patients when errors have been committed. The authors review the ethical issues involved, which generally favor disclosure unless there will be clearly be a harm that outweighs any benefit to the patient. They then discuss the practicalities involved in the disclosure, including timing, who should disclose, what should be said, handling incompetent patients, and disclosing the mistakes of other physicians.

Refs:31

Code: ADM; CORE; REL

Input date: 09/28/1998

Wu AW, McPhee SJ, Christensen JF. Mistakes in medical practice. In: Behavioral Medicine in Primary Care: a Practical Guide. New York, NY: Appleton & Lange. 1997.

This chapter in a textbook of behavioral medicine looks at the physician behaviors that contitutes mistakes and their aftermaths. The authors first review the definition, prevalence, types, causes, and circumstances of mistakes. They then address the outcomes of medical mistakes on patients and families, physicians, and the doctor-patient relationship. Most of the chapter is concerned with physician responses to mistakes, both wise and unwise. They conclude with a brief section on mistake prevention.

Code: REL

Input date: 09/28/1998