Course: Patient Safety and Medical Errors

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Readings


Topic Readings
Session 1: Science of Safety

Reason J. Human error: models and management. BMJ 2000;320:768-770

Institute of Medicine. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press, 2000

Vicente KJ: From patients to politicians: a cognitive engineering view of patient safety. Qual Saf Health Care 2002;11:302-304 (Optional)

de Leval, MR, et al. Human factors and cardiac surgery: A multicenter study. J Thorac Cardiovasc Surg 2000;119:661-672 (Optional)

Gawande A. The Checklist. New Yorker December 10, 2007.

Session 2: Adverse Events and Safety: Concepts & Definitions

Institute of Medicine. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press, 2000

  • Read Chapter 3
  • Read Glossary
Session 3: IOM Report(s)

Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press, 2001.

  • Read Executive Summary

Institute of Medicine. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press, 2000

  • Read Executive Summary
Session 4: Safety and Medicine

Zhan C, Miller MR. Excess length of stay, charges, and mortality attributable to medical injuries durin hospitalization. JAMA 2003;290:1868-1874

Sexton JB, Thomas EJ, Helmreich RL. Error, stress, and teamwork in medicine and aviation: cross sectional surveys. BMJ 2000;320:745-749

Pronovost P, Sexton B. Assessing safety culture: guidelines and recommendations. Qual Saf Health Care 2005;14:231-233

Thomas EJ, et al. The effect of executive walk rounds on nurse safety climate attitudes: a randomized trial of clinical units. BMC Health Serv Res 2005;5:28

Modak I, et al. Measuring safety culture in the ambulatory setting: The Safety Attitudes Questionnaire � Ambulatory Version. J Gen Intern Med 2007;22:1-5

Session 5: Systems of Influence Zaleznik A. Power and politics in organizational life. Harvard Business Review 1970;48:47�60 (Optional)
Session 6: Culture of Safety

Shojania KG, et al. Graduate medical eduation and patient safety: A busy - and occasionally hazardous - intersection. Ann Intern Med 2006;145:592-598 (Optional)

Sexton JB, Thomas EJ, Helmreich RL. Error, stress, and teamwork in medicine and aviation: cross sectional surveys. BMJ 2000;320:745-749

Pronovost P, Sexton B. Assessing safety culture: guidelines and recommendations. Qual Saf Health Care 2005;14:231-233

Thomas EJ, et al. The effect of executive walk rounds on nurse safety climate attitudes: a randomized trial of clinical units. BMC Health Serv Res 2005;5:28

Modak I, et al. Measuring safety culture in the ambulatory setting: The Safety Attitudes Questionnaire � Ambulatory Version. J Gen Intern Med 2007;22:1-5

Session 7: Playing in the Sandbox: Teamwork Climate, Situational Awareness, and Communication

Nielsen PE, Goldman MB, Mann S, et al. Effects of teamwork training on adverse outcomes and process of care in labor and delivery: A randomized controlled trial. Obstet Gynecol 2007;109:48-55

Pratt SD, et al. Impact of CRM-based team training on obstetric outcomes and clinicians' patient safety attitudes. Jt Comm J Qual Patient Saf. 2007;33:720-725.

Session 8: Measuring Patient Safety

Atlas SJ. Development and validation of a new health-related quality of life instrument for patients with sinusitis. Quality of Life Research 2005;14:1375-1386

Pronovost PJ. Tracking progress in patient safety: An elusive target. JAMA 2006;296:696-699

Pronovost PJ. The GAAP in quality measurement and reporting. JAMA 2007;298:1800-1802.

Pronovost PJ. A framework for health care organizations to develop and evaluate a safety scorecard. JAMA 2007;298:2063-2065.

Session 9: Adverse Event Reporting Systems

Leape LL. Reporting of adverse events. NEJM 2002;347:1633-1638

Roumm AR. Health care provider use of private sector internal error-reporting systems. Am J Med Qual 2005;20:304-312

Wu AW, et al. Development of the ICU safety reporting system. J Patient Safety 2005;1:23-32

Needham DM, et al. A system factors analysis of airway events from the Intensive Care Unit Safety Reporting System (ICUSRS). Crit Care Med 2004;32:2349-50.

Session 10: Reporting Medical Errors: Real-time Tales Pronovost PJ. Toward learning from patient safety reporting systems. J Crit Care 2006;21:305-15
Session 11: Investigating a Defect

Pronovost PJ. Acute decompensation after removing a central line: Practical approaches to increasing safety in the intensive care unit. 2004;140:1025-1033

Evans RS, et al. A computer-assisted management program for antibiotics and other antiinfective agents. N Engl J Med. 1998;338:232-238

Wu AW, et al. Effectiveness and efficiency of root cause analysis in medicine. JAMA 2008;299:685-687

Session 12: Interventions to Improve Patient Safety

Ammenwerth E, et al. Impact of CPOE on mortality rates - contradictory findings, important messages. Methods Inf Med 2006;45:586-593.

Vincent C. Understanding and responding to adverse events. N Engl J Med 2003;348:1051-1056

Woodward HI, et al. What have we learned about interventions to reduce medical errors? Annu Rev Public Health 2010;31:479-97

Berwick DM. Commentary: The science of improvement. JAMA 2008;299:1182-1184

Session 13: Practical Tools to Improve Patient Safety

Hales BM, Pronovost PJ. The checklist - a tool for error management and performance improvement. J Crit Care 2006;21:231-235 (Optional)

Pronovost PJ, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2007;355:2725-2732

Pronovost PJ, et al. Implementing and validating a comprehensive unit-based safety program. J Patient Safety 2005;1:33-40

Session 14: CUSP: Designing a Comprehensive Patient Safety Program

Wachter RM, Pronovost PJ. The 100,000 lives campaign: A scientific and policy review. Jt Comm J Qual Patient Saf2006;32:628-30

Gahdhi TK, et al. Closing the looper: follow-up and feedback in a patient safety program. Jt Comm J Qual Patient Saf 2005;31:614-21

Institute of Medicine. Patient Safety: Achieving a New Standatd for Care. Washington, DC: National Academies Press, 2004

Weissman JS, et al. Hospital workload and adverse events. Med Care 2007;45:448-455

Session 15: Medication Safety
Session 16: Disclosure of Adverse Events and Medical Errors

Wu AW, et al. To tell the truth: Ethical and practical issues in disclosing medical mistakes to patients. J Gen Intern Med 1997;12:770-775

Gallagher TH, et al. US and Canadian physicians' attitudes and experiences regarding disclosing errors to patients. Arch Intern Med. 2006;166:1605-1611

Waterman AD, et al. The emotional impact of medical errors on practicing physicians in the United States and Canada. Jt Comm J Qual Saf 2007;33:467-76.

Session 17: The Joint Commission and Patient Safety

Etchegaray, JM, et al. Differentiating close calls from errors: A multidisciplinary perspective. J Patient Safety 2005;1:133-137

Joint Commission Patient Safety Web Site

National Patient Safety Goals (NPSGs)

Session 18: Macrosystems: Policy, Payment, Regulation, Accreditation, and Education to Improve Safety

National Quality Forum

The Leapfrog Group for Patient Safety

Institute for Healthcare improvement

Mello MM, et al. Who pays for medical errors? An analysis of adverse event costs, the medical liability system, and incentive for patient safety improvement. Journal of Empirical Legal Studies 2007;4:835-860

Session 19: Safety in Surgery: What's the Data? Makary MA, et al. Operating room briefings and wrong-site surgery. J Am Coll Surg 2007;204:236-243
Session 20: Adverse Events in the Outpatient Setting Pronovost PJ. Tracking progress in patient safety: An elusive target. JAMA 2006;296:696-699 (Optional)
Session 21: An Overview of the Patient Safety Programme at WHO

Haynes AB, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009;360:491-499.

Session 22: Clean Care is Safer Care
Session 23: Overview of STOP-BSI Program Pronovost PJ, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2007;355:2725-2732
Session 24: Where are we now? Wachter RM. Patient safety at ten: Unmistakeable progress, troubling gaps. Health Affairs 2010;29:165-173