Analysis of errors reported by surgeons at three teaching hospitals

Surgery

Volumn 133, Issue 6, 2003, Pages 614-621

  Gawande, Atul A ^a   Zinner, Michael J ^a   Studdert, David M ^a   Brennan, Troyen A ^a  

^a BRIGHAM AND WOMEN S HOSPITAL   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

ARTICLE; BLEEDING; DISABILITY; EMERGENCY TREATMENT; ERROR; HOSPITAL PERSONNEL; HUMAN; INTERPERSONAL COMMUNICATION; ORGAN INJURY; PATIENT CARE; POSTOPERATIVE COMPLICATION; PRIORITY JOURNAL; RISK FACTOR; SURGEON; SURGICAL MORTALITY; SURGICAL RISK; SURGICAL TRAINING; TEACHING HOSPITAL; WOUND DEHISCENCE; WOUND INFECTION;

EID: 0037600690     PISSN: 00396060     EISSN: None     Source Type: Journal    
DOI: 10.1067/msy.2003.169     Document Type: Article

References (42)

1. Leape LL, Brennan TA, Laird N, Lawthers AG, Localio AR, Barnes BA, 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.
2. Thomas EJ, Studdert DM, Burstin HR, Orav EJ, Zeena T, Williams EJ, et al. Incidence and types of adverse events and negligent care in Utah and Colorado. Med Care 2000;38:247-9.
3. Gawande AA, Thomas EJ, Zinner MJ. The incidence and nature of surgical adverse events in Colorado and Utah in 1992. Surgery 1999;126:66-75.
4. Thomas EJ, Studdert DM, Newhouse JP, et al. Costs of medical injuries in Utah and Colorado. Inquiry 1999;36:255-64.
5. Couch NP, Tilney NL, Rayner AA, Moore FD. The high cost of low-frequency events: the anatomy and economics of surgical mishaps. N Engl J Med 1981;304:634-7.
6. Hannan EL, Siu AL, Kumar D, Chassin MR, et al. The decline of coronary artery bypass graft surgery mortality in New York State. The role of surgeon volume. JAMA 1995;273:209-13.
7. Sosa JA, Bowman HM, Tielsch JM, Powe NR, Gordon TA, Udelsman R, et al. The importance of surgeon experience for clinical and economic outcomes from thyroidectomy. Ann Surg 1998;228:320-30.
8. Ruby ST, Robinson D, Lynch JT, Mark H. Outcome analysis of carotid endarterectomy in Connecticut: the impact of volume and specialty. Ann Vasc Surg 1996;10:22-6.
9. Luft HS, Bunker JP, Enthoven AC. Should operations be regionalized? The empirical relation between surgical volume and mortality. N Engl J Med 1979;301:1364-9.
10. Hannah EL, O'Donnell JF, Kilburn H, et al. Investigation of the relationship between volume and mortality for surgical procedures performed in New York state hospitals. JAMA 1989; 262:503-510.
11. Sosa JA, Bowman HM, Gordon TA, Bass EB, Yeo CJ, Lillemoe KD, et al. Importance of hospital volume in the overall management of pancreatic cancer. Ann Surg 1998;228:428-38.
12. Sexton JB, Thomas EJ, Helmreich RL. Error, stress, and teamwork in medicine and aviation: cross sectional surveys. BMJ 2000;320:745-9.
13. Taffinder NJ, McManus IC, Gul Y, Russell RC, Darzi A. Effect of sleep deprivation on surgeons' dexterity on laparoscopy simulator. Lancet 1998;352:1191.
14. Lunn JN. The National Confidential Enquiry into Perioperative Deaths. J Clin Monitoring 1994;10:426-8.
15. Keyes C, Hammond J. Every defect is a treasure: supervision of junior staff. Intl J Qual Health Care 1997;9:391-2.
16. Leape LL. Error in medicine. JAMA 1994;272:1851-7.
17. Young GJ, Charns MP, Daley J, Forbes MG, Henderson W, Khuri SF, et al. Best practices for managing surgical services: the role of coordination. Health Care Manage Rev 1997;22:72-81.
18. Pearse RM, Dana EC, Lanigan CJ, Pook JAR. Organisational failures in urgent and emergency surgery: a potential peri-operative risk factor. Anaesthesia 2001;56:670-89.
19. Couch NP, Tilney NL, Rayner AA, Moore FD. The high cost of low-frequency events: the anatomy and economics of surgical mishaps. N Engl J Med 1981;304:634-7.
20. Andrews LB, Stocking C, Krizek T, Gottlieb L, Krizek C, Vargish T, et al. An alternative strategy for studying adverse events in medical care. Lancet 1997;349:309-13.
21. Weingart SN, Wilson RM, Gibberd RW, Harrison B. Epidemiology of medical error. BMJ 2000;320:774-7.
22. Kohn LT, Gorrigan JM, Donaldson MS, eds. To err is human: building a safer health system. Washington, DC: National Academy Press; 2000.
23. Joint Commission on Accreditation of Health Care Organizations. Root cause analysis in health care: tools and techniques. Oakbrook Terrace, IL: Joint Commission on Accreditation of Health Care Organizations; 2000.
24. Klein GA, Calderwood R, MacGregor D. Critical decision method for eliciting knowledge. IEEE Transactions on Systems, Man, and Cybernetics 1989;19:462-72.
25. Cooper JB, Newbower RS, Long CD, McPeek B. Preventable anesthesia mishaps: a study of human factors. Anesthesiology 1978;49:399-406.
26. Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR, Lawthers AG, 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.
27. Reason JT, Human error. Cambridge, MA: Cambridge University Press; 1990.
28. Feldman L, Barkun J, Barkun A, Sampalis J, Rosenberg L. Measuring postoperative complications in general surgery patients using an outcomes-based strategy: comparison with complications presented at morbidity and mortality rounds. Surgery 1997;122:711-9.
29. Brennan TA, Localio AR, Leape LL, Laird NM, Peterson L, Hiatt HH, et al. Identification of adverse events occurring during hospitalization: a cross-sectional study of litigation, quality assurance, and medical records at two teaching hospitals. Ann Intern Med 1990;112:221-6.
30. Flanagan JC. The critical incident technique. Psychological Bulletin 1954;51:327-58.
31. Crandall B, Getchell-Reiter K. Critical decision method: a technique for eliciting concrete assessment indicators from the "intuition" of NICU nurses. ANS Adv Nurs Sci 1993:16:42-51.
32. Vincent C, Taylor-Adams S, Stanhope N. Framework for analysing risk and safety in clinical medicine. BMJ 1998;316:1154-7.
33. Studdert DM, Brennan TA. No-fault compensation for medical injuries: the prospect for error prevention. JAMA 2001;286:217-23.
34. Gawande AA, Studdert DM, Orav EJ, Brennan TA, Zinner MJ. Risk factors for retained instruments and sponges after surgery. New Engl J Med 2003;348:229-35.
35. 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.
36. Cooper JB, Long CD, Newbower RS, Philips JH. Critical incidents associated with intraoperative exchanges of anesthesia personnel. Anesthesiology 1982;56:456-61.
37. Neale G, Woloshynowych M, Vincent C. Exploring the causes of adverse events in NHS hospital practice. J R Soc Med 2001;94:322-30.
38. Petersen LA, Orav EJ, Teich JM, O'Neil AC, Brennan TA. Using a computerized sign-out program to improve continuity of inpatient care and prevent adverse events. Jt Comm J Qual Improv 1998;24:77-87.
39. Loftus EF. Eyewitness testimony. 2nd Edition. Cambridge, MA: Harvard University Press; 1996.
40. Thomas EJ, Orav EJ, Brennan TA. Hospital ownership and preventable adverse events. J Gen Intern Med 2000;15:211-9.
41. Pierce EC. The 34th Rovenstine lecture. Anesthesiology 1996;84:965-75.
42. Eichhorn JH, Cooper JB, Cullen DJ, Gessner JS, Holzman RS, Maier WR, et al. Anesthesia practice standards at Harvard: a review. J Clin Anesth 1988;55:64-5.