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Volumn 13, Issue 2, 2003, Pages 125-137

Patient safety in neurosurgery: Detection of errors, prevention of errors, and disclosure of errors

Author keywords

Adverse events; Complications; Disclosure; Error; Human factors; Patient safety

Indexed keywords

CAUSE OF DEATH; DEATH; HUMAN; HUMAN FACTORS RESEARCH; IATROGENIC DISEASE; INCIDENCE; INTERPERSONAL COMMUNICATION; MEDICAL ETHICS; MEDICAL LITERATURE; NEUROSURGERY; PRIORITY JOURNAL; PROSPECTIVE STUDY; PUBLICATION; RETROSPECTIVE STUDY; REVIEW; RISK FACTOR; SAFETY; SURGEON; SURGICAL MORTALITY;

EID: 0037569572     PISSN: 10506438     EISSN: None     Source Type: Journal    
DOI: 10.1097/00013414-200306000-00008     Document Type: Review
Times cited : (19)

References (128)
  • 2
    • 0037629754 scopus 로고
    • State issues scathing report on error at Sloan-Kettering
    • November 16
    • Altman LK. State issues scathing report on error at SloanKettering. The New York Times November 16, 1995:A1, A16.
    • (1995) The New York Times
    • Altman, L.K.1
  • 3
    • 0001823287 scopus 로고    scopus 로고
    • When doctors make mistakes
    • February 1
    • Gawande A. When doctors make mistakes. The New Yorker February 1, 1999:40.
    • (1999) The New Yorker , pp. 40
    • Gawande, A.1
  • 4
    • 0025924692 scopus 로고
    • Incidence of adverse events and negligence in hospitalized patients: Results of the Harvard Medical Practice Study I
    • Brennan TA, Leape LL, Laird NM, et al. 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.
    • (1991) N Engl J Med , vol.324 , pp. 370-376
    • Brennan, T.A.1    Leape, L.L.2    Laird, N.M.3
  • 5
    • 0032807457 scopus 로고    scopus 로고
    • The incidence and nature of surgical adverse events in Colorado and Utah in 1992
    • 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.
    • (1999) Surgery , vol.126 , pp. 66-75
    • Gawande, A.A.1    Thomas, E.J.2    Zinner, M.J.3    Brennan, T.A.4
  • 6
    • 0026022279 scopus 로고
    • The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II
    • Leape LL, Brennan TA, Laird N, et al. The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. N Engl J Med 1991;324:377-84.
    • (1991) N Engl J Med , vol.324 , pp. 377-384
    • Leape, L.L.1    Brennan, T.A.2    Laird, N.3
  • 7
    • 0034931547 scopus 로고    scopus 로고
    • Exploring the causes of adverse events in NHS hospital practice
    • Neale G, Woloshynowych M, Vincent C. Exploring the causes of adverse events in NHS hospital practice. J R Soc Med 2001;94: 322-30.
    • (2001) J R Soc Med , vol.94 , pp. 322-330
    • Neale, G.1    Woloshynowych, M.2    Vincent, C.3
  • 8
    • 0034146799 scopus 로고    scopus 로고
    • Incidence and types of adverse events and negligent care in Utah and Colorado
    • Thomas EJ, Studdert DM, Burstin HR, et al. Incidence and types of adverse events and negligent care in Utah and Colorado. Med Care 2000;38:261-71.
    • (2000) Med Care , vol.38 , pp. 261-271
    • Thomas, E.J.1    Studdert, D.M.2    Burstin, H.R.3
  • 9
    • 0035799063 scopus 로고    scopus 로고
    • Adverse events in British hospitals: Preliminary retrospective record review
    • Vincent C, Neale G, Woloshynowych M. Adverse events in British hospitals: preliminary retrospective record review. BMJ 2001; 322:517-9.
    • (2001) BMJ , vol.322 , pp. 517-519
    • Vincent, C.1    Neale, G.2    Woloshynowych, M.3
  • 10
    • 0033519201 scopus 로고    scopus 로고
    • An analysis of the causes of adverse events from the Quality of Australian Health Care Study
    • Wilson RM, Harrison BT, Gibberd RW, Hamilton JD. An analysis of the causes of adverse events from the Quality of Australian Health Care Study. Med J Aust 1999;170:411-5.
    • (1999) Med J Aust , vol.170 , pp. 411-415
    • Wilson, R.M.1    Harrison, B.T.2    Gibberd, R.W.3    Hamilton, J.D.4
  • 12
    • 0027935823 scopus 로고
    • Complications of CT-guided stereotactic biopsy of intra-axial brain lesions
    • Bernstein M, Parrent AG. Complications of CT-guided stereotactic biopsy of intra-axial brain lesions. J Neurosurg 1994;81: 165-8.
    • (1994) J Neurosurg , vol.81 , pp. 165-168
    • Bernstein, M.1    Parrent, A.G.2
  • 13
    • 0027993927 scopus 로고
    • Complications of first craniotomy for intra-axial brain tumor
    • Cabantog AM, Bernstein M. Complications of first craniotomy for intra-axial brain tumor. Can J Neurol Sci 1994;21:213-8.
    • (1994) Can J Neurol Sci , vol.21 , pp. 213-218
    • Cabantog, A.M.1    Bernstein, M.2
  • 14
    • 0001076277 scopus 로고
    • The establishment of cerebral hernia as a decompressive measure for inaccessible brain tumors; With the description of intramuscular methods of making the bone defect in temporal and occipital regions
    • Cushing H. The establishment of cerebral hernia as a decompressive measure for inaccessible brain tumors; with the description of intramuscular methods of making the bone defect in temporal and occipital regions. Surg Gynecol Obstet 1905;1:297-314.
    • (1905) Surg Gynecol Obstet , vol.1 , pp. 297-314
    • Cushing, H.1
  • 15
    • 84943671882 scopus 로고
    • The surgical aspects of major neuralgia of the trigeminal nerve. A report of twenty cases of operation on the Gasserion ganglion with anatomic and physiological notes on the consequences of its removal
    • Cushing H. The surgical aspects of major neuralgia of the trigeminal nerve. A report of twenty cases of operation on the Gasserion ganglion with anatomic and physiological notes on the consequences of its removal. JAMA 1905;773-9, 860-5, 920-9, 1002-8, 1088-93.
    • (1905) JAMA , pp. 773-779
    • Cushing, H.1
  • 16
    • 0035376740 scopus 로고    scopus 로고
    • Mistakes as a social construct: An historical approach
    • Pinkus RL. Mistakes as a social construct: an historical approach. Kennedy Inst Ethics J 2001;11:117-33.
    • (2001) Kennedy Inst Ethics J , vol.11 , pp. 117-133
    • Pinkus, R.L.1
  • 17
    • 0038644262 scopus 로고    scopus 로고
    • Toronto: University of Toronto Press
    • Bliss M. William Osler: a life in medicine. Toronto: University of Toronto Press; 1999:57, 139, 259, 269.
    • (1999) William Osler: A Life in Medicine , vol.57 , pp. 139
    • Bliss, M.1
  • 18
    • 0043209695 scopus 로고
    • London: Bailliere, Tindall and Cox
    • Leeson JR. Lister as I knew him. London: Bailliere, Tindall and Cox; 1928:64, 178.
    • (1928) Lister as I Knew Him , vol.64 , pp. 178
    • Leeson, J.R.1
  • 19
    • 0004223940 scopus 로고
    • Cambridge, MA: Cambridge University Press
    • Reason JT. Human error. Cambridge, MA: Cambridge University Press; 1990.
    • (1990) Human Error
    • Reason, J.T.1
  • 20
    • 0029066463 scopus 로고
    • Incidence of adverse drug events and potential adverse drug events. Implications for prevention
    • Bates DW, Cullen DJ, Laird N, et al. Incidence of adverse drug events and potential adverse drug events. Implications for prevention. JAMA 1995;274:29-34.
    • (1995) JAMA , vol.274 , pp. 29-34
    • Bates, D.W.1    Cullen, D.J.2    Laird, N.3
  • 21
    • 0034938647 scopus 로고    scopus 로고
    • The human factor in cardiac surgery: Errors and near misses in a high technology medical domain
    • Carthey J, de Leval MR, Reason JT. The human factor in cardiac surgery: errors and near misses in a high technology medical domain. Ann Thorac Surg 2001;72:300-5.
    • (2001) Ann Thorac Surg , vol.72 , pp. 300-305
    • Carthey, J.1    De Leval, M.R.2    Reason, J.T.3
  • 23
    • 0025217417 scopus 로고
    • Fundamentals of medication error research
    • Allan EL, Barker KN. Fundamentals of medication error research. Am J Hosp Pharm 1990;47:555-71.
    • (1990) Am J Hosp Pharm , vol.47 , pp. 555-571
    • Allan, E.L.1    Barker, K.N.2
  • 25
    • 0027231164 scopus 로고
    • Incidence of adverse drug reactions in hospitalized adults
    • Bates DW, Leape LL, Petrycki S. Incidence of adverse drug reactions in hospitalized adults. J Gen Intern Med 1993;8: 289-94.
    • (1993) J Gen Intern Med , vol.8 , pp. 289-294
    • Bates, D.W.1    Leape, L.L.2    Petrycki, S.3
  • 26
    • 0026329694 scopus 로고
    • Incidence and characteristics of preventable iatrogenic cardiac arrests
    • Bedell SE, Deitz DC, Leeman D, Delbanco TL. Incidence and characteristics of preventable iatrogenic cardiac arrests. JAMA 1991;265:2815-20.
    • (1991) JAMA , vol.265 , pp. 2815-2820
    • Bedell, S.E.1    Deitz, D.C.2    Leeman, D.3    Delbanco, T.L.4
  • 27
    • 0024999043 scopus 로고
    • The myriad medication mistakes in psychiatry: A consumer's view
    • Blaska B. The myriad medication mistakes in psychiatry: a consumer's view. Hosp Commun Psychiatry 1990;41:993-8.
    • (1990) Hosp Commun Psychiatry , vol.41 , pp. 993-998
    • Blaska, B.1
  • 29
    • 0023256955 scopus 로고
    • Medication error prevention by clinical pharmacists in two children's hospitals
    • Folli HL, Poole RL, Benitz WE, Russo JC. Medication error prevention by clinical pharmacists in two children's hospitals. Pediatrics 1987;79:718-22.
    • (1987) Pediatrics , vol.79 , pp. 718-722
    • Folli, H.L.1    Poole, R.L.2    Benitz, W.E.3    Russo, J.C.4
  • 30
    • 0025145273 scopus 로고
    • Drug related admissions to a cardiology department; Frequency and avoidability
    • Hallas J, Haghfelt T, Gram LF, Grodum E, Damsbo N. Drug related admissions to a cardiology department; frequency and avoidability. J Intern Med 1990;228:379-84.
    • (1990) J Intern Med , vol.228 , pp. 379-384
    • Hallas, J.1    Haghfelt, T.2    Gram, L.F.3    Grodum, E.4    Damsbo, N.5
  • 31
    • 0027985355 scopus 로고
    • Pediatric medication errors: Predicting and preventing tenfold disasters
    • Koren G, Haslam RH. Pediatric medication errors: predicting and preventing tenfold disasters. J Clin Pharmacol 1994;34:1043-5.
    • (1994) J Clin Pharmacol , vol.34 , pp. 1043-1045
    • Koren, G.1    Haslam, R.H.2
  • 32
    • 0032522873 scopus 로고    scopus 로고
    • Incidence of adverse drug reactions in hospitalized patients. A meta-analysis of prospective studies
    • Lazarou J, Pomeranz BH, Corey PN. Incidence of adverse drug reactions in hospitalized patients. A meta-analysis of prospective studies. JAMA 1998;279:1200-5.
    • (1998) JAMA , vol.279 , pp. 1200-1205
    • Lazarou, J.1    Pomeranz, B.H.2    Corey, P.N.3
  • 33
    • 0028978123 scopus 로고
    • Systems analysis of adverse drug events
    • Leape LL, Bates DW, Cullen DJ, et al. Systems analysis of adverse drug events. JAMA 1995;274:35-43.
    • (1995) JAMA , vol.274 , pp. 35-43
    • Leape, L.L.1    Bates, D.W.2    Cullen, D.J.3
  • 35
    • 0031030450 scopus 로고    scopus 로고
    • Factors related to errors in medication prescribing
    • Lesar TS, Briceland L, Stein DS. Factors related to errors in medication prescribing. JAMA 1997;277:312-7.
    • (1997) JAMA , vol.277 , pp. 312-317
    • Lesar, T.S.1    Briceland, L.2    Stein, D.S.3
  • 37
    • 0032574258 scopus 로고    scopus 로고
    • Increase in US medication-error deaths between 1983 and 1993
    • Phillips DP, Christenfeld N, Glynn LM. Increase in US medication-error deaths between 1983 and 1993. Lancet 1998;351: 643-4.
    • (1998) Lancet , vol.351 , pp. 643-644
    • Phillips, D.P.1    Christenfeld, N.2    Glynn, L.M.3
  • 39
    • 0028307648 scopus 로고
    • Inappropriate drug prescribing for the community dwelling elderly
    • Willcox SM, Himmelstein DU, Woolhandler S. Inappropriate drug prescribing for the community dwelling elderly. JAMA 1994;272:292.
    • (1994) JAMA , vol.272 , pp. 292
    • Willcox, S.M.1    Himmelstein, D.U.2    Woolhandler, S.3
  • 40
    • 0031657948 scopus 로고    scopus 로고
    • Medication errors in pediatric practice: Insights from a continuous quality improvement approach
    • Wilson DG, McArtney RG, Newcombe RG, et al. Medication errors in pediatric practice: insights from a continuous quality improvement approach. Eur J Pediatr 1998;157:769-74.
    • (1998) Eur J Pediatr , vol.157 , pp. 769-774
    • Wilson, D.G.1    McArtney, R.G.2    Newcombe, R.G.3
  • 41
    • 0035097519 scopus 로고    scopus 로고
    • Human errors in a multidisciplinary intensive care unit: A 1-year prospective study
    • Bracco D, Favre J, Bissonnette B, et al. Human errors in a multidisciplinary intensive care unit: a 1-year prospective study. Intensive Care Med 2001;27:137-45.
    • (2001) Intensive Care Med , vol.27 , pp. 137-145
    • Bracco, D.1    Favre, J.2    Bissonnette, B.3
  • 42
    • 0029825392 scopus 로고    scopus 로고
    • Complications of care in a pediatric intensive care unit: A prospective study
    • Stambouly JJ, McLaughlin LL, Mandel FS, Boxer RA. Complications of care in a pediatric intensive care unit: a prospective study. Intensive Care Med 1996;22:1098-104.
    • (1996) Intensive Care Med , vol.22 , pp. 1098-1104
    • Stambouly, J.J.1    McLaughlin, L.L.2    Mandel, F.S.3    Boxer, R.A.4
  • 43
    • 0026750855 scopus 로고
    • An analysis of errors causing morbidity and mortality in a trauma system: A guide for quality improvement
    • Davis JW, Hoyt DB, McArdle MS, et al. An analysis of errors causing morbidity and mortality in a trauma system: a guide for quality improvement. J Trauma 1992;32:660-6.
    • (1992) J Trauma , vol.32 , pp. 660-666
    • Davis, J.W.1    Hoyt, D.B.2    McArdle, M.S.3
  • 45
    • 0024359619 scopus 로고
    • Human error in anesthesia mishaps
    • Gaba DM. Human error in anesthesia mishaps. Int Anesthesiol Clin 1989;27:137-47.
    • (1989) Int Anesthesiol Clin , vol.27 , pp. 137-147
    • Gaba, D.M.1
  • 46
    • 0031023762 scopus 로고    scopus 로고
    • An alternative strategy for studying adverse events in medical care
    • Andrews LB, Stocking C, Krizek T, et al. An alternative strategy for studying adverse events in medical care. Lancet 1997;349: 309-13.
    • (1997) Lancet , vol.349 , pp. 309-313
    • Andrews, L.B.1    Stocking, C.2    Krizek, T.3
  • 47
    • 0031963240 scopus 로고    scopus 로고
    • Avoidable deaths still occur after large bowel surgery
    • MacArthur DC, Nixon SJ, Aitken RJ. Avoidable deaths still occur after large bowel surgery. Br J Surg 1998;85:80-3.
    • (1998) Br J Surg , vol.85 , pp. 80-83
    • MacArthur, D.C.1    Nixon, S.J.2    Aitken, R.J.3
  • 48
    • 0034036870 scopus 로고    scopus 로고
    • Complications on a general surgery service: Incidence and reporting
    • Wanzel KR, Jamieson CG, Bohnen JM. Complications on a general surgery service: incidence and reporting. Can J Surg 2000; 43:113-7.
    • (2000) Can J Surg , vol.43 , pp. 113-117
    • Wanzel, K.R.1    Jamieson, C.G.2    Bohnen, J.M.3
  • 49
    • 0026776583 scopus 로고
    • Measuring and managing quality of surgery. Statistical vs incidental approaches
    • McGuire HH, Horsley JS, Salter DR, Sobel M. Measuring and managing quality of surgery. Statistical vs incidental approaches. Arch Surg 1992;127:733-8.
    • (1992) Arch Surg , vol.127 , pp. 733-738
    • McGuire, H.H.1    Horsley, J.S.2    Salter, D.R.3    Sobel, M.4
  • 50
    • 0034756452 scopus 로고    scopus 로고
    • Common bile duct injury during laparoscopic cholecystectomy and the use of intraoperative cholangiography. Adverse outcome or preventable error?
    • Flum DR, Koepsell T, Haegerty P, Sinanan M, Dellinger EP. Common bile duct injury during laparoscopic cholecystectomy and the use of intraoperative cholangiography. Adverse outcome or preventable error? Arch Surg 2001;136:1287-92.
    • (2001) Arch Surg , vol.136 , pp. 1287-1292
    • Flum, D.R.1    Koepsell, T.2    Haegerty, P.3    Sinanan, M.4    Dellinger, E.P.5
  • 51
    • 0027504140 scopus 로고
    • Potential human error in setting stereotactic coordinates for radiosurgery: Implications for quality assurance
    • Flickinger JC, Lunsford LD, Kondziolka D, Maitz A. Potential human error in setting stereotactic coordinates for radiosurgery: implications for quality assurance. Int J Radiat Oncol Biol Phys 1993;27:397-401.
    • (1993) Int J Radiat Oncol Biol Phys , vol.27 , pp. 397-401
    • Flickinger, J.C.1    Lunsford, L.D.2    Kondziolka, D.3    Maitz, A.4
  • 52
    • 0038644263 scopus 로고    scopus 로고
    • Is recording error in neurosurgery feasible and useful? A prospective study of error in 500 consecutive elective surgical cases
    • in press
    • Bernstein M, Massicotte E. Is recording error in neurosurgery feasible and useful? A prospective study of error in 500 consecutive elective surgical cases. J Neurol Neurosurg Psychiatr (in press).
    • J Neurol Neurosurg Psychiatr
    • Bernstein, M.1    Massicotte, E.2
  • 53
    • 0032556151 scopus 로고    scopus 로고
    • A computer alert system to prevent injury from adverse drug events: Development and evaluation in a community teaching hospital
    • Raschke RA, Gollihare B, Wunderlich TA, et al. A computer alert system to prevent injury from adverse drug events: development and evaluation in a community teaching hospital. JAMA 1998; 280:1317-20.
    • (1998) JAMA , vol.280 , pp. 1317-1320
    • Raschke, R.A.1    Gollihare, B.2    Wunderlich, T.A.3
  • 54
    • 0029384423 scopus 로고
    • The incident reporting system does not detect adverse drug events: A problem for quality improvement
    • Cullen DJ, Bates DW, Small SD, Cooper JB, Nemeskal AR, Leape LL. The incident reporting system does not detect adverse drug events: a problem for quality improvement. J Qual Improve 1995;21:541-8.
    • (1995) J Qual Improve , vol.21 , pp. 541-548
    • Cullen, D.J.1    Bates, D.W.2    Small, S.D.3    Cooper, J.B.4    Nemeskal, A.R.5    Leape, L.L.6
  • 55
    • 0033855538 scopus 로고    scopus 로고
    • Institutional peer review can reduce the risk and cost of carotid endarterectomy
    • Olcott C, Mitchell RS, Steinberg GK, Zarins CK. Institutional peer review can reduce the risk and cost of carotid endarterectomy. Arch Surg 2000;135:939-42.
    • (2000) Arch Surg , vol.135 , pp. 939-942
    • Olcott, C.1    Mitchell, R.S.2    Steinberg, G.K.3    Zarins, C.K.4
  • 57
    • 0029736934 scopus 로고    scopus 로고
    • Use of morning report to enhance adverse event detection
    • Welsh CH, Pedot R, Anderson RJ. Use of morning report to enhance adverse event detection. J Gen Intern Med 1996;11: 454-60.
    • (1996) J Gen Intern Med , vol.11 , pp. 454-460
    • Welsh, C.H.1    Pedot, R.2    Anderson, R.J.3
  • 58
    • 0034681753 scopus 로고    scopus 로고
    • How to investigate and analyze clinical incidents: Clinical risk unit and association of litigation and risk management protocol
    • Vincent C, Taylor-Adams S, Chapman EJ, et al. How to investigate and analyze clinical incidents: clinical risk unit and association of litigation and risk management protocol. BMJ 2000; 320:777.
    • (2000) BMJ , vol.320 , pp. 777
    • Vincent, C.1    Taylor-Adams, S.2    Chapman, E.J.3
  • 59
    • 0032507502 scopus 로고    scopus 로고
    • Framework for analyzing risk and safety in clinical medicine
    • Vincent C, Taylor-Adams S, Stanhope N. Framework for analyzing risk and safety in clinical medicine. BMJ 1998;316:1154-7.
    • (1998) BMJ , vol.316 , pp. 1154-1157
    • Vincent, C.1    Taylor-Adams, S.2    Stanhope, N.3
  • 60
    • 0028812215 scopus 로고
    • A look into the nature and causes of human errors in the intensive care unit
    • 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.
    • (1995) Crit Care Med , vol.23 , pp. 294
    • Donchin, Y.1    Gopher, D.2    Olin, M.3
  • 62
    • 0028584173 scopus 로고
    • Does housestaff discontinuity of care increase the risk for preventable adverse events?
    • Petersen LA, Brennan TA, O'Neil AC, Cook EF, Lee TH. Does housestaff discontinuity of care increase the risk for preventable adverse events? Ann Intern Med 1994;121:866-72.
    • (1994) Ann Intern Med , vol.121 , pp. 866-872
    • Petersen, L.A.1    Brennan, T.A.2    O'Neil, A.C.3    Cook, E.F.4    Lee, T.H.5
  • 63
    • 0035975409 scopus 로고    scopus 로고
    • Mortality among patients admitted to hospitals on weekends as compared with weekdays
    • Bell CM, Redelmeier DA. Mortality among patients admitted to hospitals on weekends as compared with weekdays. N Engl J Med 2001;345:663-8.
    • (2001) N Engl J Med , vol.345 , pp. 663-668
    • Bell, C.M.1    Redelmeier, D.A.2
  • 65
    • 0033994071 scopus 로고    scopus 로고
    • Effects of trauma cases on the care of patients who have chest pain in an emergency department
    • Boutros F, Redelmeier DA. Effects of trauma cases on the care of patients who have chest pain in an emergency department. J Trauma 2000;48:649-53.
    • (2000) J Trauma , vol.48 , pp. 649-653
    • Boutros, F.1    Redelmeier, D.A.2
  • 66
    • 0032071196 scopus 로고    scopus 로고
    • Applying human factors to the design of medical equipment: Patient controlled analgesia
    • Lin L, Isla R, Doniz K, Harkness H, Vicente KJ, Doyle DJ. Applying human factors to the design of medical equipment: patient controlled analgesia. J Clin Monit Comput 1998;14: 253-63.
    • (1998) J Clin Monit Comput , vol.14 , pp. 253-263
    • Lin, L.1    Isla, R.2    Doniz, K.3    Harkness, H.4    Vicente, K.J.5    Doyle, D.J.6
  • 67
    • 0030768682 scopus 로고    scopus 로고
    • Errors in MR stereotaxy due to undetected extraneous metal objects
    • Condon B, Hadley D. Errors in MR stereotaxy due to undetected extraneous metal objects. Phys Med Biol 1997;42:1779-89.
    • (1997) Phys Med Biol , vol.42 , pp. 1779-1789
    • Condon, B.1    Hadley, D.2
  • 68
    • 0036125702 scopus 로고    scopus 로고
    • Team communications in the operating room: Talk patterns, sites of tension, and implications for novices
    • Lingard L, Reznick R, Espin S, Regehr G, DeVito I. Team communications in the operating room: talk patterns, sites of tension, and implications for novices. Acad Med 2002;77:232-7.
    • (2002) Acad Med , vol.77 , pp. 232-237
    • Lingard, L.1    Reznick, R.2    Espin, S.3    Regehr, G.4    DeVito, I.5
  • 69
    • 0034681797 scopus 로고    scopus 로고
    • Error, stress, and teamwork in medicine and aviation: Cross sectional surveys
    • Sexton JB, Thomas EJ, Helmreich RL. Error, stress, and teamwork in medicine and aviation: cross sectional surveys. BMJ 2000;320:745-9.
    • (2000) BMJ , vol.320 , pp. 745-749
    • Sexton, J.B.1    Thomas, E.J.2    Helmreich, R.L.3
  • 70
    • 12544260773 scopus 로고    scopus 로고
    • Comparison of self-reporting of deficiencies in airway management with video analyses of actual performance
    • Mackenzie CF, Jefferies NJ, Hunter WA, et al. Comparison of self-reporting of deficiencies in airway management with video analyses of actual performance. Hum Factors 1996;38:623-35.
    • (1996) Hum Factors , vol.38 , pp. 623-635
    • Mackenzie, C.F.1    Jefferies, N.J.2    Hunter, W.A.3
  • 72
    • 0030898422 scopus 로고    scopus 로고
    • Cognitive performance and mood after a weekend on call in a surgical unit
    • Wesnes KA, Walker MB, Walker LG, et al. Cognitive performance and mood after a weekend on call in a surgical unit. Br J Surg 1997;84:493-5.
    • (1997) Br J Surg , vol.84 , pp. 493-495
    • Wesnes, K.A.1    Walker, M.B.2    Walker, L.G.3
  • 73
    • 0032505606 scopus 로고    scopus 로고
    • Effect of sleep deprivation on surgeons' dexterity on laparoscopy simulator
    • Taffinder NJ, McManus IC, Gul Y, Russell RC, Darzi A. Effect of sleep deprivation on surgeons' dexterity on laparoscopy simulator. Lancet 1998;352:1191.
    • (1998) Lancet , vol.352 , pp. 1191
    • Taffinder, N.J.1    McManus, I.C.2    Gul, Y.3    Russell, R.C.4    Darzi, A.5
  • 74
    • 0028113704 scopus 로고
    • Relationship of day versus night sleep to physician performance and mood
    • Smith-Coggins R, Rosekind MR, Hurd S, Buccino KR. Relationship of day versus night sleep to physician performance and mood. Ann Emerg Med 1994;24:928-34.
    • (1994) Ann Emerg Med , vol.24 , pp. 928-934
    • Smith-Coggins, R.1    Rosekind, M.R.2    Hurd, S.3    Buccino, K.R.4
  • 75
    • 1842335052 scopus 로고    scopus 로고
    • Fatigue, alcohol, and performance impairment
    • Dawson D, Reid K. Fatigue, alcohol, and performance impairment. Nature 1997;388:235.
    • (1997) Nature , vol.388 , pp. 235
    • Dawson, D.1    Reid, K.2
  • 76
    • 0024524717 scopus 로고
    • Cognitive errors in diagnosis: Instantiation, classification, and consequences
    • Kassirer JP, Kopelman RI. Cognitive errors in diagnosis: instantiation, classification, and consequences. Am J Med 1989;86: 433-41.
    • (1989) Am J Med , vol.86 , pp. 433-441
    • Kassirer, J.P.1    Kopelman, R.I.2
  • 77
    • 0037629730 scopus 로고    scopus 로고
    • The Leapfrog Group. Available at: http://www.leapfroggroup. org. Accessed January 28, 2003.
    • (2003)
  • 78
    • 0022611341 scopus 로고
    • Training resident physicians in fiberoptic sigmoidoscopy. How many supervised examinations are required to achieve competence?
    • Hawes R, Lehman GA, Hast J, et al. Training resident physicians in fiberoptic sigmoidoscopy. How many supervised examinations are required to achieve competence? Am J Med 1986;80:465-70.
    • (1986) Am J Med , vol.80 , pp. 465-470
    • Hawes, R.1    Lehman, G.A.2    Hast, J.3
  • 79
    • 0033407104 scopus 로고    scopus 로고
    • Safety and efficacy of total thyroidectomy in hands of endocrine surgery trainees
    • Mishra A, Agarwal G, Agarwal A, Mishra SK. Safety and efficacy of total thyroidectomy in hands of endocrine surgery trainees. Am J Surg 1999;178:377-80.
    • (1999) Am J Surg , vol.178 , pp. 377-380
    • Mishra, A.1    Agarwal, G.2    Agarwal, A.3    Mishra, S.K.4
  • 80
    • 0035102961 scopus 로고    scopus 로고
    • The influence of surgical specialty training on the outcomes of elective abdominal aortic aneurysm surgery
    • Tu JV, Austin PC, Johnston KW. The influence of surgical specialty training on the outcomes of elective abdominal aortic aneurysm surgery. J Vasc Surg 2001;33:447-52.
    • (2001) J Vasc Surg , vol.33 , pp. 447-452
    • Tu, J.V.1    Austin, P.C.2    Johnston, K.W.3
  • 81
    • 0034785510 scopus 로고    scopus 로고
    • Bile duct injury during laparoscopic cholecystectomy: Results of a national survey
    • Archer SB, Brown DW, Smith CD, Branum GD, Hunter JG. Bile duct injury during laparoscopic cholecystectomy: results of a national survey. Ann Surg 2001;234:549-58.
    • (2001) Ann Surg , vol.234 , pp. 549-558
    • Archer, S.B.1    Brown, D.W.2    Smith, C.D.3    Branum, G.D.4    Hunter, J.G.5
  • 82
    • 0032556180 scopus 로고    scopus 로고
    • Effect of computerized physician order entry and a team intervention on prevention of serious medication errors
    • Bates DW, Leape LL, Cullen DJ, et al. Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. JAMA 1998;280:1311-6.
    • (1998) JAMA , vol.280 , pp. 1311-1316
    • Bates, D.W.1    Leape, L.L.2    Cullen, D.J.3
  • 83
    • 0033591952 scopus 로고    scopus 로고
    • Pharmacist participation on physician rounds and adverse drug events in the intensive care unit
    • Leape LL, Cullen DJ, Clapp MD, et al. Pharmacist participation on physician rounds and adverse drug events in the intensive care unit. JAMA 1999;282:267-70.
    • (1999) JAMA , vol.282 , pp. 267-270
    • Leape, L.L.1    Cullen, D.J.2    Clapp, M.D.3
  • 84
    • 0036304279 scopus 로고    scopus 로고
    • Reengineering intravenous drug and fluid administration processes in the operating room. Step one: Task analysis of existing processes
    • Fraind DB, Slagle JM, Tubbesing VA, Hughes SA, Weinger MB. Reengineering intravenous drug and fluid administration processes in the operating room. Step one: task analysis of existing processes. Anesthesiology 2002;97:139-47.
    • (2002) Anesthesiology , vol.97 , pp. 139-147
    • Fraind, D.B.1    Slagle, J.M.2    Tubbesing, V.A.3    Hughes, S.A.4    Weinger, M.B.5
  • 85
    • 0036489344 scopus 로고    scopus 로고
    • Combating omission errors through task analysis and good reminders
    • Reason J. Combating omission errors through task analysis and good reminders. Qual Safety Health Care 2002;11:40-4.
    • (2002) Qual Safety Health Care , vol.11 , pp. 40-44
    • Reason, J.1
  • 87
  • 88
    • 0027425784 scopus 로고
    • How house officers cope with their mistakes
    • Wu AW, Folkman S, McPhee SJ, Lo B. How house officers cope with their mistakes. West J Med 1993;159:565-9.
    • (1993) West J Med , vol.159 , pp. 565-569
    • Wu, A.W.1    Folkman, S.2    McPhee, S.J.3    Lo, B.4
  • 89
    • 0036211250 scopus 로고    scopus 로고
    • A role for error training in surgical technical skill instruction and evaluation
    • Rogers DA, Regehr G, MacDonald J. A role for error training in surgical technical skill instruction and evaluation. Am J Surg 2002;183:242-5.
    • (2002) Am J Surg , vol.183 , pp. 242-245
    • Rogers, D.A.1    Regehr, G.2    MacDonald, J.3
  • 90
    • 0038644230 scopus 로고    scopus 로고
    • Human factors
    • Graeber C. Human factors. Aero [serial online] 1999. Available at: http://www.boeing.com/commercial/aeromagazine/aero_08/human_textonly.html. Accessed January 28, 2003.
    • (1999) Aero
    • Graeber, C.1
  • 91
    • 0035486819 scopus 로고    scopus 로고
    • Developing and deploying a patient safety program in a large health care delivery system: You can't fix what you don't know about
    • Bagian JP, Lee C, Gosbee J, et al. Developing and deploying a patient safety program in a large health care delivery system: you can't fix what you don't know about. Jt Comm J Qual Improv 2001;27:522-32.
    • (2001) Jt Comm J Qual Improv , vol.27 , pp. 522-532
    • Bagian, J.P.1    Lee, C.2    Gosbee, J.3
  • 92
    • 0037968006 scopus 로고    scopus 로고
    • National Center for Patient Safety. Available at: http://www.patientsafety.gov. Accessed January 28, 2003.
  • 93
    • 0037015167 scopus 로고    scopus 로고
    • Are bad outcomes from questionable clinical decisions preventable medical errors? A case of cascade iatrogenesis
    • Hofer T, Hayward R. Are bad outcomes from questionable clinical decisions preventable medical errors? A case of cascade iatrogenesis. Ann Intern Med 2002;137:327-33.
    • (2002) Ann Intern Med , vol.137 , pp. 327-333
    • Hofer, T.1    Hayward, R.2
  • 94
    • 0032820220 scopus 로고    scopus 로고
    • Ethical problems in surgery: Innovation leading to unforeseen complications
    • McKneally MF. Ethical problems in surgery: innovation leading to unforeseen complications. World J Surg 1999;23:786-8.
    • (1999) World J Surg , vol.23 , pp. 786-788
    • McKneally, M.F.1
  • 95
    • 0028320520 scopus 로고
    • Erroneous placement of side indicators of brain CT
    • Altinors N. Erroneous placement of side indicators of brain CT. AJNR Am J Neuroradiol 1994;15:197.
    • (1994) AJNR Am J Neuroradiol , vol.15 , pp. 197
    • Altinors, N.1
  • 96
    • 0037395699 scopus 로고    scopus 로고
    • Wrong-side surgery: Systems for prevention
    • Bernstein M. Wrong-side surgery: systems for prevention. Can J Surg 2003;46:144-146.
    • (2003) Can J Surg , vol.46 , pp. 144-146
    • Bernstein, M.1
  • 97
    • 0033763429 scopus 로고    scopus 로고
    • Evaluation of error in medicine: Application of a public health model
    • Brasel KJ, Layde PM, Hargarten S. Evaluation of error in medicine: application of a public health model. Acad Emerg Med 2000;7:1298-302.
    • (2000) Acad Emerg Med , vol.7 , pp. 1298-1302
    • Brasel, K.J.1    Layde, P.M.2    Hargarten, S.3
  • 98
    • 0036551264 scopus 로고    scopus 로고
    • Side markings of the neonatal chest X-ray: Two legal cases of pneumothorax side mix up
    • Finnbogason T, Bremmer S, Ringertz H. Side markings of the neonatal chest X-ray: two legal cases of pneumothorax side mix up. Eur Radiol 2002;12:938-41.
    • (2002) Eur Radiol , vol.12 , pp. 938-941
    • Finnbogason, T.1    Bremmer, S.2    Ringertz, H.3
  • 99
    • 0027675207 scopus 로고
    • The Australian Incident Monitoring Study. Problems with regional anesthesia: An analysis of 2000 incident reports
    • Fox MA, Webb RK, Singleton R, Ludbrook G, Runciman WB. The Australian Incident Monitoring Study. Problems with regional anesthesia: an analysis of 2000 incident reports. Anaesth Intensive Care 1993;21:646-9.
    • (1993) Anaesth Intensive Care , vol.21 , pp. 646-649
    • Fox, M.A.1    Webb, R.K.2    Singleton, R.3    Ludbrook, G.4    Runciman, W.B.5
  • 100
    • 0036632834 scopus 로고    scopus 로고
    • First do no harm: Integrating patient safety and quality improvement
    • Mawji Z, Stillman P, Laskowski R, et al. First do no harm: integrating patient safety and quality improvement. Jt Comm J Qual Improv 2002;28:373-86.
    • (2002) Jt Comm J Qual Improv , vol.28 , pp. 373-386
    • Mawji, Z.1    Stillman, P.2    Laskowski, R.3
  • 103
    • 0025439646 scopus 로고
    • Operation on the wrong side. An avoidable adverse event
    • Wender SS. Operation on the wrong side. An avoidable adverse event. J Fla Med Assoc 1990;77:585-6.
    • (1990) J Fla Med Assoc , vol.77 , pp. 585-586
    • Wender, S.S.1
  • 104
    • 0038305275 scopus 로고    scopus 로고
    • Oregon Association of Hospitals and Health Systems. Hints on Preventing Surgery on the Wrong Site. Available at: http://www.aracnet.com/oahhs/issues/safety/surgery.htm. Accessed January 28, 2003.
    • (2003) Hints on Preventing Surgery on the Wrong Site
  • 105
    • 0035916318 scopus 로고    scopus 로고
    • Bioethics for clinicians: 23. Disclosure of medical error
    • Hebert PC, Levin AV, Robertson G. Bioethics for clinicians: 23. Disclosure of medical error. Can Med Assoc J 2001;164:509-13.
    • (2001) Can Med Assoc J , vol.164 , pp. 509-513
    • Hebert, P.C.1    Levin, A.V.2    Robertson, G.3
  • 106
    • 0035376746 scopus 로고    scopus 로고
    • Institutional responses to medical mistakes: Ethical and legal perspectives
    • Thurman AE. Institutional responses to medical mistakes: ethical and legal perspectives. Kennedy Inst Ethics J 2001;11:147-56.
    • (2001) Kennedy Inst Ethics J , vol.11 , pp. 147-156
    • Thurman, A.E.1
  • 111
    • 0037968003 scopus 로고    scopus 로고
    • Medical Audio Visual Communications Inc. MAVC Group of Companies. Available at: http://www.mavc.com. Accessed October 18, 2002.
  • 112
    • 0029837119 scopus 로고    scopus 로고
    • How do patients want physicians to handle mistakes? A survey of internal medicine patients in an academic setting
    • Witman AB, Park DM, Hardin SB. How do patients want physicians to handle mistakes? A survey of internal medicine patients in an academic setting. Arch Intern Med 1996;156:2565-9.
    • (1996) Arch Intern Med , vol.156 , pp. 2565-2569
    • Witman, A.B.1    Park, D.M.2    Hardin, S.B.3
  • 113
    • 0037022219 scopus 로고    scopus 로고
    • Medical Professionalism Project. ACP, ABIM, EFIM. Ann Intern Med 2002;136:243-6.
    • (2002) Ann Intern Med , vol.136 , pp. 243-246
  • 114
    • 0019613355 scopus 로고
    • Disclosure of injury and illness: Responsibilities in the physician-patient relationship
    • LeBlang TR. Disclosure of injury and illness: responsibilities in the physician-patient relationship. Law Med Health Care 1981; 9:4-7.
    • (1981) Law Med Health Care , vol.9 , pp. 4-7
    • LeBlang, T.R.1
  • 117
    • 0033593073 scopus 로고    scopus 로고
    • Risk management: Extreme honesty may be the best policy
    • Kraman SS, Hamm G. Risk management: extreme honesty may be the best policy. Ann Intern Med 1999;131:963-7.
    • (1999) Ann Intern Med , vol.131 , pp. 963-967
    • Kraman, S.S.1    Hamm, G.2
  • 118
    • 0031052862 scopus 로고    scopus 로고
    • Physician-patient communication. The relationship with malpractice claims among primary care physicians and surgeons
    • Levinson W, Roter DL, Mullooly JP, Dull VT, Frankel RM. Physician-patient communication. The relationship with malpractice claims among primary care physicians and surgeons. JAMA 1997;277:553-9.
    • (1997) JAMA , vol.277 , pp. 553-559
    • Levinson, W.1    Roter, D.L.2    Mullooly, J.P.3    Dull, V.T.4    Frankel, R.M.5
  • 119
    • 0035806405 scopus 로고    scopus 로고
    • Enforcing a new openness: JCAHCO to hospitals: Let patients know when their care hasn't met standards
    • Tieman J. Enforcing a new openness: JCAHCO to hospitals: let patients know when their care hasn't met standards. Mod Healthc 2001;31:4-5. Available at: http://www.modernhealthcare.com. Accessed October 9, 2002.
    • (2001) Mod Healthc , vol.31 , pp. 4-5
    • Tieman, J.1
  • 120
    • 0033066236 scopus 로고    scopus 로고
    • Error in medicine: Legal impediments to US reform
    • Liang B. Error in medicine: legal impediments to US reform. J Health Polit Policy Law 1999;24:27-58.
    • (1999) J Health Polit Policy Law , vol.24 , pp. 27-58
    • Liang, B.1
  • 121
    • 0035468495 scopus 로고    scopus 로고
    • The adverse event of unaddressed medical error: Identifying and filling the holes in the health-care and legal systems
    • Liang BA. The adverse event of unaddressed medical error: identifying and filling the holes in the health-care and legal systems. J Law Med Ethics 2001;29:346-68.
    • (2001) J Law Med Ethics , vol.29 , pp. 346-368
    • Liang, B.A.1
  • 122
    • 0032942425 scopus 로고    scopus 로고
    • Reasons for not reporting adverse events: An empirical study
    • Vincent C, Stanhope N, Crowley-Murphy M. Reasons for not reporting adverse events: an empirical study. J Eval Clin Pract 1999;5:13-21.
    • (1999) J Eval Clin Pract , vol.5 , pp. 13-21
    • Vincent, C.1    Stanhope, N.2    Crowley-Murphy, M.3
  • 123
    • 0033528454 scopus 로고    scopus 로고
    • Patients' and doctors' attitudes to amount of information given after unintended injury during treatment: Cross-sectional questionnaire survey
    • 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: 640-1.
    • (1999) BMJ , vol.318 , pp. 640-641
    • Hingorani, M.1    Wong, T.2    Vafidis, G.3
  • 124
    • 0031435205 scopus 로고    scopus 로고
    • To tell the truth. Ethical and practical issues in disclosing medical mistakes to patients
    • Wu AW, Cavanagh TA, McPhee SJ, Lo B, Micco GP. To tell the truth. Ethical and practical issues in disclosing medical mistakes to patients. J Gen Intern Med 1997;12:770.
    • (1997) J Gen Intern Med , vol.12 , pp. 770
    • Wu, A.W.1    Cavanagh, T.A.2    McPhee, S.J.3    Lo, B.4    Micco, G.P.5
  • 125
    • 0030077445 scopus 로고    scopus 로고
    • The emotional impact of mistakes on family physicians
    • Newman MC. The emotional impact of mistakes on family physicians. Arch Fam Med 1996;5:71-5.
    • (1996) Arch Fam Med , vol.5 , pp. 71-75
    • Newman, M.C.1
  • 127
    • 0033761871 scopus 로고    scopus 로고
    • Surgical error: Ethical issues of adverse events
    • Krizek T. Surgical error: ethical issues of adverse events. Arch Surg 2000;135:1359-66.
    • (2000) Arch Surg , vol.135 , pp. 1359-1366
    • Krizek, T.1


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