Reducing health care hazards: Lessons from the Commercial Aviation Safety Team

Health Affairs

Volumn 28, Issue 3, 2009, Pages

  Pronovost, Peter J ^a   Goeschel, Christine A ^a   Olsen, Kyle L ^b   Pham, Julius C ^a   Miller, Marlene R ^b,c   Berenholtz, Sean M ^a   Sexton, J Bryan ^a   Marsteller, Jill A ^d   Morlock, Laura L ^d   Wu, Albert W ^d   Loeb, Jerod M ^e   Clancy, Carolyn M ^f  

^a JOHNS HOPKINS UNIVERSITY SCHOOL OF MEDICINE   (United States)

^b Department of Pediatrics ^*

^c JOHNS HOPKINS CHILDREN S CENTER   (United States)

^d JOHNS HOPKINS BLOOMBERG SCHOOL OF PUBLIC HEALTH   (United States)

^e Joint Commission   (United States)

^f AGENCY FOR HEALTHCARE RESEARCH AND QUALITY   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

ACCIDENT PREVENTION; AIRCRAFT ACCIDENT; ARTICLE; AVIATION; FATALITY; HEALTH CARE; HEALTH CARE QUALITY; HEALTH HAZARD; PATIENT SAFETY; RISK ASSESSMENT;

ACCIDENTS, AVIATION; CLINICAL TRIALS DATA MONITORING COMMITTEES; COOPERATIVE BEHAVIOR; DATABASES, FACTUAL; FORECASTING; HEALTH CARE REFORM; HEALTH POLICY; HUMANS; INTERDISCIPLINARY COMMUNICATION; MEDICAL ERRORS; QUALITY OF HEALTH CARE; RISK MANAGEMENT; SAFETY MANAGEMENT; UNITED STATES;

EID: 66749128517     PISSN: 02782715     EISSN: 15445208     Source Type: Journal    
DOI: 10.1377/hlthaff.28.3.w479     Document Type: Article

References (28)

1. J.M. Corrigan, L.T. Kohn, and M.S. Donaldson, eds., To Err Is Human: Building a Safer Health System (Washington: National Academies Press, 1999).
2. R.M. Wachter, "The End of the Beginning: Patient Safety Five Years after 'To Err Is Human'," Health Affairs 23 (2004): w534-w545 (published online 30 November 2004; 10.1377/hlthaff.w4.534);
3. and D. Altman, C. Clancy, and R. Blendon, "Improving Patient Safety - Five Years after the IOM Report," New England Journal of Medicine 351, no. 20 (2004): 2041-2043. (Pubitemid 39482495)
4. Joint Commission, "Sentinel Events," http://www. jointcommission.org/SentinelEvents (accessed 19 March 2009);
5. A.W. Wu, A.K. Lipshutz, and P.J. Pronovost, "The Effectiveness and Efficiency of Root Cause Analysis," Journal of the American Medical Association 299, no. 6 (2008): 685-687;
6. and P.J. Pronovost et al., "A Practical Tool to Learn from Defects in Patient Care," Joint Commission Journal on Quality and Safety 32, no. 2 (2006): 102-108.
7. See the CAST home page, http://www.cast-safety.org.
8. P. Pronovost et al., "An Intervention to Decrease Catheter-Related Bloodstream Infections in the ICU," New England Journal of Medicine 355, no. 26 (2006): 2725-2732;
9. A. Gawande, "The Checklist," New Yorker, 10 December 2007;
10. and "Reduction in Central Line-Associated Bloodstream Infections among Patients in Intensive Care Units - Pennsylvania, April 2001-March 2005," Morbidity and Mortality Weekly Report 54, no. 40 (2005): 1013-1016.
11. See Aviation Safety Network, "Accident Description," http://aviation-safety.net/database/record.php?id=19951220-1 (accessed 19 March 2009).
12. J. Burin, "2005: The Year in Review - Return of the Killers," July 2006, http://www.flightsafety.org/asw/july06/asw-jul06-p17-22.pdf (accessed 26 March 2009).
13. J. Gosbee, "Human Factors Engineering and Patient Safety," Quality and Safety in Health Care 11, no. 4 (2002): 352-354. (Pubitemid 35463392)
14. J. Dorsch and S. Dorsch, Understanding Anesthesia Equipment (Philadelphia: Lippincott Williams and Wilkins, 1999).
15. M.S. Eisenberg and T.J. Mengert, "Cardiac Resuscitation," New England Journal of Medicine 344, no. 17 (2001): 1304-1313.
16. P.S. Chan et al., "Delayed Time to Defibrillation after In-Hospital Cardiac Arrest," New England Journal of Medicine 358, no. 1 (2008): 9-17.
17. Dorsch and Dorsch, Understanding Anesthesia Equipment.
18. G.A. Miller, "The Magical Number Seven, Plus or Minus Two: Some Limits on Our Capacity for Processing Information (1956)," Psychological Review 101, no. 2 (1994): 343-352. (Pubitemid 24976805)
19. Joint Commission, "2009 National Patient Safety Goals," http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/ 09-hap-npsgs.htm (accessed 26 March 2009);
20. and C.G. Holzmueller et al., "Medication Reconciliation: Are We Meeting the Requirement?" Journal of Clinical Outcomes Management 13, no. 8 (2006): 441-444. (Pubitemid 44463190)
21. A graphical version of this model is available online at http://content.healthaffairs.org/cgi/content/full/hlthaff.28.3.w479/DC2.
22. Chan et al., "Delayed Time to Defibrillation."
23. K. Kahol et al., "Effect of Fatigue on Psychomotor and Cognitive Skills," American Journal of Surgery 195, no. 2 (2008): 195-204.
24. Wu et al., "The Effectiveness and Efficiency."
25. P.J. Pronovost et al., "Framework for Patient Safety Research and Improvement," Circulation 119, no. 2 (2009): 330-337;
26. and P.J. Pronovost, S.M. Berenholtz, and D.M. Needham, "Translating Evidence into Practice: A Model for Large Scale Knowledge Translation," BMJ 337 (2008): a1714.
27. Pronovost et al. "Framework for Patient Safety Research."
28. C. Zhan et al., "Medicare Payment for Selected Adverse Events: Building the Business Case for Investing in Patient Safety," Health Affairs 25, no. 5 (2006): 1386-1393.