Beyond the medical record: Other modes of error acknowledgment

Journal of General Internal Medicine

Volumn 20, Issue 5, 2005, Pages 404-409

  Rosenthal, Marilynn M ^a   Cornett, Patricia L ^b   Sutcliffe, Kathleen M ^c   Lewton, Elizabeth ^c  

^a UNIVERSITY OF MICHIGAN MEDICAL SCHOOL   (United States)

^b UNIVERSITY OF MICHIGAN   (United States)

^c UNIVERSITY OF MICHIGAN   (United States)

Author keywords

Counting medical errors; Medical error; Medical error acknowledgement; Medical mistake

Indexed keywords

ARTICLE; ERROR ACKNOWLEDGMENT; HUMAN; INFORMAL DISCUSSION; INTERPERSONAL COMMUNICATION; INTERVIEW; MEDICAL DOCUMENTATION; MEDICAL ERROR; MEDICAL RECORD; MEDICATION ERROR; NEAR MISS; NORMAL HUMAN; OUTCOMES RESEARCH; PATIENT CARE; QUALITATIVE ANALYSIS; RESIDENT; SUPERVISORY DISCUSSION; TEACHING HOSPITAL;

ADULT; DOCUMENTATION; GYNECOLOGY; HUMANS; INTERNAL MEDICINE; INTERNSHIP AND RESIDENCY; MEDICAL ERRORS; MEDICAL RECORDS; MEDICATION ERRORS; OBSTETRICS; RISK MANAGEMENT; SURGERY; UNITED STATES;

EID: 22144486301     PISSN: 08848734     EISSN: None     Source Type: Journal    
DOI: 10.1111/j.1525-1497.2005.0098.x     Document Type: Article

References (35)

1. Kohn LT, Corrigan JM, Donaldson MS, eds. To Error Is Human. Building a Safer Health System. Institute of Medicine. Washington, DC: National Academy Press; 1999.
2. Brennan TA. The Institute of Medicine report on medical errors - could it do harm? N Engl J Med. 2000;342:1123-5.
3. Becher EC, Chassin MR. Improving quality, minimizing error: making it happen. Health Aff. 2001;20:68-81.
4. McDonald CJ, Weiner M, Hui SL. Deaths due to medical errors are exaggerated In Institute of Medicine report. JAMA. 2000;284:93-5.
5. Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study 1. N Engl J Med. 1991;324:370-6.
6. Leape LL, Brennan TA, Laird NM, 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.
7. Bates DW, Gawande AA. Error in medicine: what have we learned? Ann Intern Med. 2000;132:763-7.
8. Barach P, Berwick DM. Patient safety and the reliability of health care systems. Ann Intern Med. 2003;138:997-8.
9. Barach P, Small SD. Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems. Br Med J. 2000;320: 759-63.
10. Thomas EJ, Studdert DM, Brennan TA. The reliability of medical record review for estimating adverse event rates. Ann Intern Med. 2002;136: 812-6.
11. Hayward RA, Hofer TP. Estimating hospital deaths due to medical errors: preventability is in the eye of the reviewer. JAMA. 2001;286:415-20.
12. Hofer TP, Kerr EA. What is an error? Eff Clin Pract. 2000;6:261-9.
13. Vincent C. Understanding and responding to adverse events. N Engl J Med. 2003;348:1051-6.
14. Leape L, Epstein AM, Hamel MB. A series on patient safety. N Engl J Med. 2002;347:1272-3.
15. Helmreich RL, Schaefer HG. Team performance in the operating room. In: Bogner MS, ed. Human Error in Medicine. Hillsdale, NJ: Lawrence Erlbaum Associates: 1994:225-53.
16. Weick KE, Sutcliffe KM. Hospitals as cultures of entrapment. Calif Manage Rev. 2003;45:73-84.
17. Rosenthal M. The Incompetent Doctor: Behind Closed Doors. Buckingham, UK: Open University Press: 1995.
18. Reason J. Human Error. Oxford, UK: Cambridge University Press; 1990.
19. Weick K. Organizational culture as a source of high reliability. Calif Manage Rev. 29:112-27.
20. Campion EW. A death at Duke. N Engl J Med. 2003;348:1083-4.
21. Gaba DM, Howard SK. Fatigue among clinicians and the safety of patients. N Engl J Med. 2002;347:1249-55.
22. Battles JB, Shea CE. A system of analyzing medical errors to improve GME curricula and programs. Acad Med. 2001;76:125-33.
23. de Leval MR, Carthey J, Wright DF, Farewell VT, Reason JT. Human factors and cardiac surgery: a multicenter study. J Thorac Cardiovasc Surg. 2000;119:661-72.
24. Sorokin R, Claves JL, Kane GC, Gottlieb JE. The near miss resident conference: understanding the barriers to confronting medical errors. Semin Med Pract. 2002;5:12-9.
25. Adye B. Quality begets patient safety. Am J Surg. 2001;181:389-92.
26. Schmidt CE, Bottini T. Improving medication safety and patient care in the emergency department. J Emerg Nurs. 2003;29:12-6.
27. Biddle C, Oaster TRF. Investigating the nature of the morbidity and mortality conference. Acad Med. 1990;65:420.
28. Feldman L, 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. Harbison SP, Regehr G. Faculty and resident opinions regarding the role of morbidity and mortality conference. Am J Surg. 1999;177: 136-9.
30. Kinzie JD, Maricle RA, Bloom JD, et al. Improving quality assurance through psychiatric mortality and morbidity conferences in a university hospital. Hosp Community Psychiatry. 1992;43:470-4.
31. Renfrew DL, Franken EA, Berbaum KS, Weigelt FH, Abu-Yousef MM. Error in radiology: classification and lessons in 182 cases presented at a problem case conference. Radiology. 1992;183:145-50.
32. Shapiro J, Larsen K, Jacokes D. The psychosocial M & M: a tool in reinterpreting problematic medical situations. Fam Med. 1990;22: 437-42.
33. Thompson JS, Prior MA. Quality assurance and morbidity and mortality conference. J Surg Res. 1992;52:97-100.
34. Zipper L, Cushman SW. Lessons in Patient Safety. Chicago, IL: National Patient Safety Foundation; 2001.
35. Webster's New International Dictionary of the English Language. 2nd edition unabridged. Springfield, MA: G and G Merriam Company; 1961.