Critical incidents;Kritische zwischenfälle

Therapeutische Umschau

Volumn 62, Issue 3, 2005, Pages 169-174

  Scheidegger, Daniel ^a  

^a UNIVERSITY HOSPITAL BASEL   (Switzerland)

Author keywords

[No Author keywords available]

Indexed keywords

CULTURAL ANTHROPOLOGY; HEALTH CARE PERSONNEL; HEALTH CARE SYSTEM; HUMAN; INCIDENT REPORTING; MEDICAL DECISION MAKING; MEDICAL DOCUMENTATION; MEDICAL EDUCATION; MEDICAL ERROR; MEDICAL PROFESSION; PRACTICE GUIDELINE; REVIEW; RISK MANAGEMENT; SAFETY; STRESS;

HUMANS; MANDATORY REPORTING; MEDICAL ERRORS; QUALITY ASSURANCE, HEALTH CARE; RISK MANAGEMENT; SAFETY MANAGEMENT; SWITZERLAND; SYSTEMS ANALYSIS;

EID: 15544375466     PISSN: 00405930     EISSN: None     Source Type: Journal    
DOI: 10.1024/0040-5930.62.3.169     Document Type: Review

References (30)

1. Brennan TA, Leape LL, Laird N, et al. Incidents of adverse events and negligence in hospitalised patients: results of the Harvard Medical Practice Study I New England Journal of Medicine, 1991; 324: 370-6.
2. Leape LL, Brennan TA, Laird N et al. The nature of adverse events in hospitalised patients: results of the Harvard Medical Practice Study II. New England journal of Medicine, 1991; 324: 377-84.
3. Garcia Martin M, Lardelli-Claret P, Bueno-Kavanillas A et al. Proportion of hospital deaths associated with adverse events. Journal Clinical Epidemiology, 1997; 15: 1319-26.
4. Wilson RM, Runciman WB, Gibberd RW et al. The Quality in Australian Health Care Study. Med J Aust 1995; 163: 458-71.
5. Vincent CA. Risk safety and the dark side of quality. British Medical Journal 1997: 314: 1775-6.
6. Reason JT. Human error: models and management. BMJ 2000; 320: 768-70.
7. Reason JT. Managing the risks of organizational accidents. 1997. Hampshire, England, Ashgate Publishing Company.
8. Leape LL, Error in Medicine JAMA, 1994, 272: 1851-1857.
9. Graber M, Gordon R, Franklin N. Reducing Diagnostic Errors in medicine: What's the goal. Acad Med 2002; 77: 981-92.
10. Nolan TW. System changes to improve patient safety. BMJ 2000; 320: 771-3.
11. Allen La Pointe NM, Jollis JG. Medication errors in hospitalized cardiovascular patients. Arch Intern Med 2003; 163: 1461-6.
12. Kohn LT, Corrigan JM and Donaldson MS Eds. To Err is Human: building a safer health system. Institute of Medicine, National Academy Press, Washington DC 1999. www.nap.edu
13. An organisation with a memory. Report of an expert group on learning from adverse events in the NHS chaired by the Chief Medical Officer. The Stationary Office, London, 2000.
14. Brunner HH, Conen D, Günter P, von Gunten M, Huber F, Kehrer B, Komorowski A, Langenegger M, Scheidegger D, Schneider R, Suter P, Vincent C, Weber O. Asafer Healthcare system. Proposal for a national programme on patient safety improvement for Switzerland, www.swiss-q.org 2001.
15. Zhan C, Miller MR. Excess Length of stay, charges, and mortality attributable to medical injuries during Hospitalization. JAMA 2003; 290: 1868-74.
16. Weingart SN, Iezzoni LI. Looking for medical injuries where the light is bright. JAMA 2003; 290: 1917-9.
17. Barach P, Small SD. Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems. BMJ 2000; 320: 759-63.
18. Staender S, Kaufmann M, Scheidegger D: Human recoveries in the management of critical incidents in anaesthesiology. Proc Am Nat Pat Assoc 1999.
19. Staender S, Kaufmann M, Scheidegger D. Critical Incident Reporting Systems in anaesthesia. In: Vincent C, de Mol B, editors. Safety in Medicine, Oxford: Pergamon, Elsevier Science, 2000: 65-82.
20. Runciman WB, Webb RK, Lee R et al. System Failure: An analysis of 2000 incident reports. Anaesthesia and Intensive care 1993; 21: 684-95.
21. Cooper JB, Newbower RS, Long CD, McPeek B. Preventable anesthesia mishaps: a study of human factors. Qual Safe Health Care 2002; 11: 277-83.
22. Runciman WB, Moller J. Iatrogenic Injury in Australia. Australian Patient Safety Foundation ISBN 0-646-41132-2 www.apsf.net.au
23. Gawande AA, Zinner MJ, Studert DM, Brennan TA. Analysis of error reported by surgeons at three teaching hospitals. Surgery 2003; 133: 614-21.
24. Diehl A. Does Cockpit Management Training Reduce Aircrew Error?, USAF Safety Agency, Norton AFB, CAL, am 22nd Annual Seminar of The International Society of Air Safety Investigators (Canberra Australia, Nov 91).
25. Runciman WB, Merry AF, Tito F. Error, Blame and the Law in Health Care - An Antipodean Perspective. Ann Intern Med 2003; 138: 974-9.
26. NTSB, Safety Study, a review of flightcrew-involved major accidents of U.S. carriers, 1978 through 1990,
27. NTSB/SS-94/01.
28. Helmreich et al. Reinforcing and evaluating Crew Resource Management: Evaluator/LOS Instr. Ref. Manual, 1991, NASA/UT Technical Manual 90-2.
29. JAA (Joint Aviation Authorities, Hoofddorp), Joint Aviation Requirements OPS 1, 1998.
30. U.S. Government/NASA, Report of the Presidential Commission on the Space Shuttle «Challenger» accident. 1986, Washington D.C., U.S. Gov.