Summary & References (MS)

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Summary

Throughout this course, we have provided significant information to assist clinicians to understand the ongoing history of medical errors, the costs associated with those errors, and government actions in response to the information presented in IOM 1 and 2. We have provided techniques and processes to eliminate errors in the clinic and hopefully provided enough insight to help each and everyone be comfortable to admit mistakes so that others can learn, new processes can be developed, and those mistakes will not continue to occur. The aviation industry has reported near misses for years to try and gain insight and to avert actual disasters. So let us leave you with this thought from, “The Best Offense is a Good Defense Against Medical Errors”.

“Raise your hand if you treat patients in any way, Keep your hand up if you have ever made an error/mistake in taking care of a patient, If you put your hand down, I bet you are lying, We have all made mistakes, let’s hope they were near misses.”

References

Allen, M. (September 20, 2013). How Many Die From Medical Mistakes in U.S. Hospitals? Retrieved from http://www.npr.org/blogs/health/2013/09/20/224507654/how-many-die-from-medical-mistakes-in-hospitals

Andel, C., Davidow, S., Hollander, M., and Moreno, DA. (Fall 2012). The Economics of Health Care Quality and Medical Errors. Journal of Health Care Finance, Vol. 30 (1).

Bell, l. Patient Safety and Medical Error Recovery. American Journal of Critical Care. 19(6): 510, 2010 Nov.

Classen, DC., et al., (April 2011). Global Trigger Tool Shows That Adverse Events in Hospitals May be Ten Times Greater Than Previously Measured. Health Affairs, Project Hope. Bethesda, MD.

Eisenberg, JM. (Jan. 20, 2000). The Best Offense is a Good Defense Against Medical Errors: Putting the Full-Court Press on Medical Errors. Agency for Healthcare Research and Quality at Duke University Clinical Research Institute. Rockville, MD. Retrieved from http://www.ahrq.gov/news.spch012000.htm.

Gandhi, TK., Lee, TH. Patient Safety Beyond the Hospital. New England Journal of Medicine. 363(11):1001-3, 2010 Sept. 9.

Gibbons, M. (2008). Making It Safe To Pursue Safety. Retrieved from http://physical-therapy.advanceweb.com/article/the-war-on-medical-errors-5.aspx?cp=3

Impact of Working Conditions on Patient Safety. (2002). Agency for Healthcare Research and Quality. Retrieved from http://www.ahrq.gov/research/findings/factsheets/errors-safety/workfact.index.htm

New Hospital Engagement Guide: AHRQ Releases New Guide to Help Hospitals, Patients and Families in Their Healthcare. (July 2013). Agency for Healthcare Research and Quality. Rockville, MD. Retrieved from http://www.ahrq.gov/news/newsroom/press-releases/2013/patfamengagepr.html

Medical Errors and the Institute of Medicine (IOM) – Patient Safety. (2014). Retrieved from https://www.premierinc.com/safety/topics/patient_safety/index_l.jsp

Medical Errors Cost Health Care System Billions. (2011). National Journal. Retrieved from http://www.nationaljournal.com/healthcare/medical-errors-cost-health-care-system-billions-20110407

New AHRQ Toolkit Helps Make Care Safer for Patients in Medical Offices: Focus on preventing problems managing lab tests and results. (Sept. 2013).

Agency for Healthcare Research and Quality. Rockville, MD. Retrieved from http://www.AHRQ.gov/news/press-releases/2013/medoffice-toolkitpr.html

Preventable Medical Errors-The Sixth Biggest Killer in America. (2014). The American Association for Justice. Washington, DC. Retrieved from http://www.justice.org/cps/rde/justice/hs.xsl/8677.htm

Preventing Medical Errors: Avoid Blame Game, But Punish Habitual Offenders. (Sept. 30, 2009). Retrieved from http://www.hopkinsmedicine.org/news/media/releases/preventing-medical-errors-avoid-blame-game-but-punish-habitual-offenders

Radley, D.C., Wasserman, M.R., Olsho, L.W., Shoemaker, S.J., Spranca, M.D., Bradshaw, B. (2012). Reduction in Medication Errors in Hospitals due to Adoption of Computerized Provider Order Entry Systems. Journal of American Medical Informatics Association. Retrieved from http://jamia.bjm.com/content/early/2013/01/27/amiajni-2012-001241.full

Rooney, J.J., & Vanden Heuvel, L.N. (July 2004). Root Cause Analysis for Beginners. Retrieved from https://servicelink.pinnacol.com/pinnacol_docs/lp/cdrom_web/safety/management/accident_investigation/Root_Cause.pdf

Root Cause Analysis. (2008). Agency for Healthcare Research and Quality. Retrieved from http://www.psnet.ahrq.gov/primer.aspx?primeriD=10

Root Cause Analysis History. (2014). Retrieved from http://asq.org/learn-about-quality/root-cause-analysis/overview/roots-of-root-cause.html

Root Cause Analysis Processes & Methods. (2014). Retrieved from http://asq.org/learn-about-quality/root-cause-analysis/overview/conducting-root-cause.html

Root Cause Analysis (RCA). (2014). Retrieved from http://asq.org/learn-about-quality/root-cause-analysis/overview/overview.html

Root Cause Analysis, Tracing a Problem to its Origins. (2011). Retrieved from http://www.mindtools.com/pages/article/newTMC_80.htm

Rouner, J., (2011). Outpatient Medical Errors May Surpass Those In Hospitals. Retrieved from http://www.npr.org/blogs/health/2011/06/15/137199398/think-you-re-safer-from-medical-errors-outside-the-hospital-think-again

Sherwin, J. (May 2011). Contemporary Topics in Health Care: Root Cause Analysis. Retrieved from http://www.apta.org/PTinMotion/2011/5/Feature/RootCauseAnalysis

Thomas, E.J. (Fall 1999). Costs of Medical Injuries in Utah and Colorado. Inquiry, 36:255-264.

To Err is Human: Building a Better Health System. (1999). Institute of Medicine (IOM). National Academy Press. Washington, DC.

20 Tips to Help Prevent Medical Errors: Patient Fact Sheet. (Sept. 2011). Agency for Healthcare Research and Quality, Rockville, MD. Retrieved from http://www.ahrq.gov/patients-consumers/care-planning/errors/20tips/index.html

Vincent, C. Patient Safety. London: Elsevier; 2006.

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