Patient Safety & High Value Care

Expectations

Teaching Activities

Assessment

 

References

“To Err is Human”, report from the Institute of Medicine

http://www.iom.edu/~/media/Files/Report%20Files/1999/To-Err-is-Human/To%20Err%20is%20Human%201999%20%20report%20brief.pdf

This is a brief summary of the seminal report that drew the public’s attention to the issue of medical errors and consequently has driven the medical community to take more aggressive action to address this problem.

VA National Center for Patient Safety

http://www.patientsafety.va.gov/

This site gives a brief overview of root cause analysis.

Wachter RM, Shojania KG, et al. Learning from our mistakes: quality grand rounds, a new case-based series on medical errors and patient safety. Ann Int Med. 2002;136:850-2

This editorial introduces the series “Quality Grand Rounds” in the Annals of Internal Medicine. The following is a list of the articles in that series along with the website for the abstract:

1. Advance Care Planning for Fatal Chronic Illness: Avoiding Commonplace Errors and Unwanted Suffering. Lynn J, Goldstein NE. Ann Int Med 2003;138:812-8.

http://annals.org/article.aspx?articleid=716425

2. A hospitalization from Hell: A Patient’s Perspective on Quality. Cleary PD. Ann Int Med 2003; 138:33-9.

http://annals.org/article.aspx?articleid=715889

3. Hospital-Onset Infections: A Patient Safety Issue. Gerberding JL. Ann Int Med 2002; 137:665-70.

http://annals.org/article.aspx?articleid=715724

4. Unexpected Hypoglycemia in a Critically Ill Patient. Bates DW. Ann Int Med 2002; 137:110-6.

http://annals.org/article.aspx?articleid=715438

5. Are Bad Outcomes from Questionable Clinical Decisions Preventable Medical Errors? A Case of Cascade Iatrogensis. Hofer TP, Hayward RA. Ann Int Med 2002; 137:327-33.

www.annals.org/issues/v137n5/abs/200209030-00008.html

6. The Wrong Patient. Chassin MR, Becher EC. Ann Int Med 2002; 136:826-33.

http://annals.org/article.aspx?articleid=715318

Volpp KGM, Grande D. Residents’ Suggestions for reducing errors in teaching hospitals. N Engl J Med. 2003; 348(9): 851-5.

Bates DW, Gawande AA. Improving safety with information technology. N Engl J Med. 2003; 348(25): 2526-4.

Gandhi TK, Weingart SN, et al. Adverse drug events in ambulatory care. N Engl J Med. 2003; 348(16): 1556-64.

Complications: A Surgeon’s Notes on an Imperfect Science, Atul Gawande, M.D. 2003, Picador, 288 pages.

This is an excellent, highly readable book written by Dr. Gawande when he was a surgical resident. He addresses many types of errors through the use of compelling stories. This was a NY Times notable book.