Patient safety: A curriculum for teaching patient safety in emergency medicine

Academic Emergency Medicine

Volumn 10, Issue 1, 2003, Pages 69-78

  Cosby, Karen S ^b   Croskerry, Pat ^a  

^a DALHOUSIE UNIVERSITY   (Canada)

^b NONE

Author keywords

Curriculum; Emergency medicine; Patient safety

Indexed keywords

CERTIFICATION; CURRICULUM; EMERGENCY MEDICINE; EXPERIENCE; HEALTH CARE DELIVERY; HEALTH CARE QUALITY; HEALTH CARE SYSTEM; MEDICAL DECISION MAKING; MEDICAL EDUCATION; MEDICAL PRACTICE; PATIENT CARE; PRACTICE GUIDELINE; PRIORITY JOURNAL; QUALITY CONTROL; REVIEW; RISK ASSESSMENT; SAFETY; TEACHING; TECHNIQUE;

CURRICULUM; EMERGENCY MEDICINE; HUMANS; SAFETY;

EID: 0037224537     PISSN: 10696563     EISSN: None     Source Type: Journal    
DOI: 10.1197/aemj.10.1.69     Document Type: Review

References (74)

1. Croskerry P, Wears RL, Binder LS. Setting the educational agenda and curriculum for error prevention in emergency medicine. Acad Emerg Med. 2000; 7:1194-200.
2. Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR, Lawthers AG. Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study I. N Engl J Med. 1991; 324:370-6.
3. Leape LL, Brennan TA, Laird N, Lawthers AG, Localio AR, Barnes BA. The nature of adverse events in hospitalized patients: results of the Harvard Medical Practice Study II. N Engl J Med. 1991; 324:377-84.
4. Kohn LT, Corrigan JM, Donaldson MS (eds). To Err Is Human: Building a Safer Health System. Institute of Medicine. Washington, DC: National Academy Press, 2000.
5. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press, 2001.
6. 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(1):66-75.
7. Fleming ST. Complications, adverse events, and iatrogenesis: classifications and quality of care measurement issues. Clin Perform Qual Health Care. 1996; 4:137-47.
8. Wilson RM, Runciman WB, Gibberd RW, Harrison BT, Newby L, Hamilton JD. The Quality in Australian Health Care Study. Med J Aust. 1995; 163:458-71.
9. Leape LL. Error in medicine. JAMA. 1994; 272:1851-7.
10. Donchin Y, Gopher D, Olin M, et al. A look into the nature and causes of human errors in the intensive care unit. Crit Care Med. 1995; 23:294-300.
11. Bedell SE, Deitz DC, Leeman D, Delbanco TL. Incidence and characteristics of preventable iatrogenic cardiac arrests. JAMA. 1991; 265:2815-20.
12. Leape LL. The preventability of medical injury. In: Bogner MS (ed). Human Error in Medicine. Hillsdale, NJ: Lawrence Erlbaum Associates, 1994, pp 13-25.
13. Croskerry P, Sinclair D. Emergency medicine: a practice prone to error? Can J Emerg Med. 2001; 3:271-6.
14. Croskerry P. The feedback sanction. Acad Emerg Med. 2000; 7:1232-8.
15. Chisholm CD, Collison EK, Nelson DR, Cordell WH. Emergency department workplace interruptions: are emergency physicians "interrupt-driven" and "multitasking"? Acad Emerg Med. 2000; 7:1239-43.
16. Shepherd A, Kostopoulou O. Fragmentation in care and the potential for human error. In: Johnson C (ed). Proceedings of the First Workshop on Human Error and Clinical Systems. Glasgow Accident Analysis Group Technical Report G99-1. Glasgow: Glasgow Accident Analysis Group, 1999.
17. Pilpel D, Schor R, Benbassat J. Barriers to acceptance of medical error: the case for a teaching programme. Med Educ. 1998; 32:3-7.
18. Kohn LT, Corrigan JM, Donaldson MS, eds. To Err Is Human: Building a Safer Health System. Institute of Medicine. Washington, D.C.: National Academy Press; 2000, pp 210-1. Appendix B: Glossary and Acronyms.
19. Handler JA, Gillam M, Sanders AB, Klasco R. Defining, identifying, and measuring error in emergency medicine. Acad Emerg Med. 2000; 7:1183-8.
20. Meurer S. Patient Safety Term Glossary [e-mail attachment]. The Patient Safety Discussion Forum 〈PATIENT- SAFETY-@LISTSERV.NPSF.ORG〉, item #1728 (Aug 22, 2001). Available at: http://patientsafety-l@listserv.npsf.org/SCRIPTS/WA-NPSF.EXE?A2=n ind0108&L=PATIENTSAFETY-L&P=R11365. Accessed Jun 2002.
21. Senders JW, Moray NP. Human Error: Cause, Prediction, and Reduction. Hillsdale, NJ: Lawrence Erlbaum Associates, 1991.
22. Reason J. Human error: models and management. BMJ. 2000; 320:768-70.
23. Reason J. Managing the Risks of Organizational Accidents. Burlington, VT: Ashgate Publishing Company, 1997.
24. Joint Commission on Accreditation of Healthcare Organizations. What Every Hospital Should Know About Sentinel Events. Oakbrook, IL: JCAHO, 2000.
25. Vincent C, Taylor-Adams S, Stanhope N. Framework for analysing risk and safety in clinical medicine. BMJ. 1998; 316:1154-7.
26. Brasel KJ, Layde PM, Hargarten S. Evaluation of error in medicine: application of a public health model. Acad Emerg Med. 2000; 7:1298-302.
27. Haddon W Jr. A logical framework for categorizing highway safety phenomena and activity. J Trauma. 1972; 12: 193-207.
28. Helmreich RL, Schaefer H. Team performance in the operating room. In: Bogner MS (ed). Human Error in Medicine. Hillsdale, NJ: Lawrence Erlbaum Associates, 1994, pp 225-53.
29. Helmreich RL. On error management: lessons from aviation. BMJ. 2000; 320:781-5.
30. Leveson NG. Hazard analysis models and techniques. In: Safeware: System Safety and Computers: A Guide to Preventing Accidents and Losses Caused by Technology. Reading, MA: Addison-Wesley Publishing Company, 1995, pp 313-58.
31. VA National Center for Patient Safety. Healthcare Failure Mode and Effects Analysis Course Materials (HFMEA™). Available at: http://www.patientsafety.gov/HFMEA. html. Accessed June 2002.
32. DeRosier J, Stalhandske E, Bagian JP, Nudell T. Using healthcare failure mode and effects analysis™: The VA National Center for Patient Safety's Prospective Risk Analysis System. Jt Comm J Qual Improve. 2002; 27:248-67.
33. Croskerry P. The cognitive imperative: thinking about how we think. Acad Emerg Med. 2000; 7:1223-31.
34. Kassirer JP, Kopelman RI. Learning Clinical Reasoning. Baltimore: Williams & Wilkins, 1991.
35. Kovacs G, Croskerry P. Clinical decision making: an emergency medicine perspective. Acad Emerg Med. 1999; 6:947-52.
36. Kassirer JP, Kopelman RI. Use and interpretation of diagnostic tests. In: Learning Clinical Reasoning. Baltimore: Williams & Wilkins, 1991, pp 17-28.
37. McNeil BJ, Keeler E, Adelstein SJ. Primer on certain elements of medical decision making. N Engl J Med. 1975; 293:211-5.
38. Sacket DL, Straus SE, Richardson WS, Rosenberg W, Haynes RB. Evidence-Based Medicine: How to Practice and Teach EBM. 2nd ed. New York, NY: Livingstone, 2000.
39. Corrall CJ, Wyer PC, Zick LS, Bockrath CR. Evidence-based emergency medicine. How to find evidence when you need it. Part 1: databases, search programs, and strategies. Ann Emerg Med. 2002; 39:302-6.
40. Elstein AS. Heuristics and biases: selected errors in clinical reasoning. Acad Med. 1999; 74:791-4.
41. Kahneman D, Slovic P, Tversky A. Judgment Under Uncertainty: Heuristics and Biases. Cambridge, UK: Cambridge University Press, 1982.
42. Tversky A, Kahneman D. Judgment under uncertainty: heuristics and biases. Science. 1974; 185:1124-31.
43. Redelmeier DA, Ferris LE, Tu JV, Hux JE, Schull MJ. Problems for clinical judgment: introducing cognitive psychology as one more basic science. Can Med Assoc J. 2001; 164:358-60.
44. Simon HA. Reason in Human Affairs. London: Basil Blackwell, 1983.
45. Croskerry P. Avoiding pitfalls in the emergency room. Can J Contin Med Educ. 1996; Apr:1-10.
46. Elstein AS, Holzman GB, Ravitch MM, et al. Comparison of physicians' decisions regarding estrogen replacement therapy for menopausal women and decisions derived from a decision analytic model. Am J Med. 1986; 80:246-58.
47. Gruppen LD, Margolin J, Wisdom K, Grum CM. Outcome bias and cognitive dissonance in evaluating treatment decisions. Acad Med. 1994; 69(10 suppl):S57-S59.
48. Tversky A, Kahneman D. Availability: a heuristic for judging frequency and probability. Cogn Psychol. 1973; 5: 207-32.
49. Croskerry P. Cognitive forcing strategies in clinical decision making. Philadelphia, PA: Presented at the annual meeting of the Society for Academic Emergency Medicine, May 2001.
50. Freeman L, Antill T. Ten things emergency physicians should not do, unless they want to become defendants. American College of Emergency Physicians, Foresight: Risk Management for Emergency Physicians. Sept 2000; 49:1-11.
51. Harwood-Nuss A, Wolfson AB, Linden CH, Shepherd SM, Stenklyft PH (eds). The Clinical Practice of Emergency Medicine. 3rd ed. Philadelphia: Lippincott Williams and Wilkins, 2001.
52. Ely JW, Levinson W, Elder NC, Mainous AG 3rd, Vinson DC. Perceived causes of family physicians' errors. J Fam Pract. 1995; 40:337-44.
53. McClanahan S, Goodwin ST, Houser F. A formula for errors: good people + bad systems. In: Spath PL (ed). Error Reduction in Health Care: A Systems Approach to Improving Patient Safety. San Francisco, CA: Jossey-Bass, 2000, pp 1-15.
54. Sagan SD. The Limits of Safety: Organization, Accidents and Weapons. Trenton, NJ: Princeton University Press, 1993.
55. Kohn LT, Corrigan JM, Donaldson MS. Creating safety systems in health care organizations. In: Kohn LT, Corrigan JM, Donaldson MS (eds). To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press, 2000, pp 155-201.
56. Risser DT, Rice MM, Salisbury ML, Simon R, Jay GD, Berns SD. The potential for improved teamwork to reduce medical errors in the emergency department. Ann Emerg Med. 1999; 34:373-83.
57. Spath PL. Reducing errors through work system improvements. In: Spath PL (ed). Error Reduction in Health Care. A Systems Approach to Improving Patient Safety. San Francisco, CA: Jossey-Bass, 2000, pp 199-234.
58. Lightning Calculator. The Red Bead Experiment. Available at: http://www.qualitytng.com/REDBEAD.HTM. Accessed Feb 2002.
59. Bhasale A. The wrong diagnosis: identifying causes of potentially adverse events in general practice using incident monitoring. Fam Pract. 1998; 15:308-18.
60. West E. Organisational sources of safety and danger: sociological contributions to the study of adverse events. Qual Health Care. 2000; 9:120-6.
61. Risser DT, Simon R, Rice MM, Salisbury ML. A structured teamwork system to reduce clinical errors. In: Spath PL (ed). Error Reduction in Health Care: A Systems Approach to Improving Patient Safety. San Francisco, CA: Jossey-Bass, 2000, pp 235-78.
62. Marsch SCU, Harms C, Scheidegger DH. Enhancing team performance. In: Vincent C, De Mol B (eds). Safety in Medicine. Oxford, UK: Elsevier Science Ltd., 2000, pp 139-53.
63. Bates DW. Using information technology to reduce rates of medication errors in hospitals. BMJ. 2000; 320:788-91.
64. Hyman WA. Errors in the use of medical equipment. In: Bogner MS (ed). Human Error in Medicine. Hillsdale, NJ: Lawrence Erlbaum Associates, 1994, pp 327-47.
65. Casey S. Set Phasers on Stun and Other True Tales of Design, Technology, and Human Error. 2nd ed. Santa Barbara, CA: Aegean Publishing Company, 1998.
66. Hale A. Approaching safety in healthcare: from medical errors to healthy organizations. In: Vincent C, de Mol B (eds). Safety in Medicine. Amsterdam: Pergamon, 2000 pp 247-61.
67. Nolan TW. System changes to improve patient safety. BMJ. 2000; 320:771-3.
68. 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; 6:312-23.
69. Stahlhut RW, Gosbee JW, Gardner-Bonneau DJ. A human-centered approach to medical informatics for medical students, residents, and practicing clinicians. Acad Med. 1997; 72:881-7.
70. Woods D. Moving Forward on Patient Safety: Inquiry, Innovation, and Learning. Available at: http://www.uth. tmc.edu/schools/sahs/SpeakerSeries/woods2-99.html. Accessed Feb 2002.
71. Christensen JF, Levinson W, Dunn PM. The heart of darkness: the impact of perceived mistakes on physicians. J Gen Intern Med. 1992; 7:424-31.
72. Wu AW, Folkman S, McPhee SJ, Lo B. How house officers cope with their mistakes. West J Med. 1993; 159: 565-9.
73. Wusthoff CJ. MSJAMA: medical mistakes and disclosure: the role of the medical student. JAMA. 2001; 286:1080-1.
74. AMA principles of ethics. See American Medical Association. Principles of Medical Ethics. Available at: www. ama-assn.org/ama/pub/category/2512.html. Accessed Aug 2001.