Health Care Mistakes, Violations and Patient Safety

Health Care Errors and Patient Safety

Volumn , Issue , 2009, Pages 1-22

  Hurwitz, Brian ^a   Sheikh, Aziz ^b  

^a KING'S COLLEGE LONDON   (United Kingdom)

^b UNIVERSITY OF EDINBURGH   (United Kingdom)

Author keywords

Deliberate deviations from rules or codes known as violations; Erring and moral judgment; Health care mistakes, violations and patient safety; Learning from errors and violations; Learning from health care errors far less individually centred activity; Multidisciplinary perspective on safety; Patient safety; Relevance of Murphy's law according to reason; Safety of health care today at the nexus of empirical, ethical, legal and policy considerations worldwide; To err is human building a safer health system

Indexed keywords

EID: 77955058742     PISSN: None     EISSN: None     Source Type: Book    
DOI: 10.1002/9781444308150.ch1     Document Type: Chapter

References (102)

1. Bates D. The epistemology of error in late Enlightenment France. Eighteenth-Century Studies 1996; 29: 307-27.
2. Tonks A. Patient safety. Safer by design. British Medical Journal 2008; 336: 186-8. Available at http://www.bmj.com 3 National Patient Safety Association, Saferhealthcare: http://www.saferhealthcare.org. uk/ihi.
3. Institute of Medicine. To err is human: building a safer health system. In: Kohn LT, Corrigan JM, Donaldson MS, eds. Errors in Health Care: A Leading Cause of Death and Injury. National Academy Press, Washington, 1999: 160-84.
4. Department of Health. An Organisation with a Memory: Report of an Expert Group on Learning from Adverse Events in the NHS. HMSO, London, 2000.
5. Department of Health. Building a Safer NHS for Patients - Implementing an Organisation with a Memory. HMSO, London, 2001.
6. Donaldson L. Building a Safer NHS for Patients: Improving Medication Safety. A Report by the Chief Pharmaceutical Officer. Department of Health, London, 2004. Available at http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4071443.
7. Agency for Healthcare Research and Quality. Medical Errors and Patient Safety. AHRQ, London, 2003. Available at http://www.ahrq.gov/qual/errorsix.htm.
8. National Patient Safety Agency, NHS Safety Division, UK: http://www.npsa.nhs.uk/patientsafety/.
9. Institute for Safe Medication Practices, USA: http://www.ismp.org/.
10. National Coordinating Council for Medication Error Prevention and Reporting, USA: www.nccmerp.org.
11. Leape LL. Error in medicine. Journal of the American Medical Association 1994; 272: 1851-7.
12. Royal S, Smeaton L, Avery AJ, Hurwitz B, Sheikh A. Interventions in primary care to reduce medication related adverse events and hospital admissions: systematic review and meta-analysis Quality and Safety in Health Care 2006; 15: 23-31.
13. Berger J. Signatures of the Invisible. A conference convened by the European Organisation for Nuclear Research, the London Institute and the Gulbenkian Foundation, Lisbon, 2002. (Quoted in Virilio P. The Original Accident. Polity Press, London, 2007: 12.)
14. Hurwitz B. Erring and learning in clinical practice. British Journal of General Practice 2002; 52: S26-S30.
15. Horton R. The uses of errors. Lancet 1999; 353: 422-3.
16. Reason J. Understanding adverse events: the human factor. In: Vincent C, ed. Clinical Risk Management, 2nd edn. BMJ Books, London, 2001: 9-30.
17. Gorovitz S, MacIntyre A. Toward a Theory of Medical Fallibility. Hastings Center Report Vol. 5, No. 6. 1975: 13-23.
18. Quick O. Outing medical errors: questions of trust and responsibility. Medical Law Review 2006; 14 (1): 22-43.
19. Besnard D, Baxter G. Human Compensations for Undependable Systems. Technical Reports Series No. CS TR 819. University of Newcastle upon Tyne, Newcastle, 2003. Available at http://rogue.ncl.ac.uk/file_store/trs/819.pdf.
20. Reason J. Human Error. Cambridge University Press, Cambridge, MA, 1992.
21. Merry A, McCall-Smith A. Errors, Medicine and the Law. Cambridge University Press, Cambridge, 2001.
22. Irshad T, Worth A, Sheikh A. Are translation and interpretation services a necessity or a luxury? Diversity in Health and Social Care 2007; 4: 87-9.
23. Hon G. On Kepler's awareness of the problem of experimental error. Annals of Science 1987: 44; 545-91.
24. Urban M. The Man who Broke Napoleon's Codes. Faber and Faber, London, 2001.
25. Hacking I. Representing and Intervening. Cambridge University Press, Cambridge, 1984.
26. Hon G 'If this be error': probing experiment with error. In: Heidelberger M, Steinle F, eds. Experimental Essays - Versuche zum Experiment. Nomos, Baden Baden, 1998: 227-48.
27. (cited in Schickore J. (Ab)using the past for present purposes: exposing contextual and trans-contextual features of error. Perspectives on Science 2002; 10: 433-56.)
28. Allchin D. Error types. Perspectives on Science 2001; 9: 3858.
29. Frader JE. Mistakes in medicine: personal and moral responses. In: Rubin SB, Zoloth L, eds. Margin of Error. University Publishing Group, Hagerstown, MD: 2000: 113-29.
30. André J. Humility reconsidered. In: Rubin SB, Zoloth L, eds. Margin of Error. University Publishing Group, Hagerstown, MD, 2000: 59-72.
31. Freud S. The Psychopathology of Everyday Life. Penguin Freud Library (Richards A, ed.). Penguin Books, Hamondsworth, 1976.
32. Strachey J. Introduction. In: Freud S. The Psychopathology of Everyday Life. Penguin Freud Library (Richards A, ed.). Penguin Books, Hamondsworth, 1976: 31-6.
33. Senders JW, Moray NP, eds. Human Error. Lawrence Erlbaum Associates, Inc., NJ, 1991.
34. Kollarits J. Observations on dyspraxias (errors of action). Comparing errors in speaking, reading and writing. Manuscript, 1937 (Personal communication from John Senders 2006.)
35. Anonymous. Unit 5: Medication Errors. Available at http://www.mindspring.com/~mgilula/Unit5.pdf (accessed January 2008).
36. Dean B, Schacter M, Vincent C, Barber N. Causes of prescribing errors in hospital inpatients: a prospective study. Lancet 2002; 359: 1373-8.
37. Cresswell KM, Fernando B, McKinstry B, Sheikh A. Adverse drug events in the elderly. British Medical Bulletin 2007; 1-16.
38. Peabody F. The care of the patient. Journal of the American Medical Association 1927; 88: 877-82.
39. Sharpe VA, Faden AI. Medical Harm. Cambridge University Press, Cambridge, 1998.
40. Ödergård S. From punishment to prevention? Safety Science Monitor 1999; 3: 1-10.
41. Schimmel EM. The hazards of hospitalization. Annals of Internal Medicine 1964; 60: 100-10.
42. Mills DH, ed. Report on the Medical Insurance Feasibility Study. Sutter Publications, San Francisco, 1977.
43. Steel K, Gertman PM, Crescenzi C et al. Iatrogenic illness on a general medical service at a university hospital. New England Journal of Medicine 1981; 304: 638-42.
44. Lesar TS, Briceland LL, Delcoure K et al. Medication prescribing errors in a teaching hospital Journal of the American Medical Association 1990; 263: 2329-34.
45. Clasen DC, Pstonik SL, Evans RS, Burke JP. Computerised surveillance of adverse drug events in hospital patients. Journal of the American Medical Association 1991; 266: 2847-51.
46. Brennan TA, Leape LL, Laird N et al. Incidence of adverse events and negligence of hospitalized patients: report of the Harvard medical practice study I. New England Journal of Medicine 1991; 324: 370-6.
47. Leape LL, Brennan TA, Laird N et al. The nature of adverse events in hospitalized patients: report of the Harvard medical practice study II. New England Journal of Medicine 1991; 324: 377-84.
48. Baker GR, Norton PG, Flintoft V et al. The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada. Canadian Medical Journal 2004; 17 (11): 1678-86.
49. Vincent C, Neal G, Woloshynowych M. Adverse events in British hospitals: preliminary retrospective record review. British Medical Journal 2001; 322: 517-19.
50. Kohn LT, Corrigan JM, Donaldson MS, eds. To Err Is Human: Building a Safer Health System. Committee on Quality of Health Care in America, Institute of Medicine, 1999. Available at http://www.nap.edu/catalog/9728.html.
51. Berlinger N. After Harm. Johns Hopkins University Press, Baltimore, 2005.
52. Perrow C. Normal Accidents - Living with High Risk Technologies. Basic Books, New York, 1984.
53. Rasmussen J. Information Processing and Human-Machine Interaction: An Approach to Cognitive Engineering. New Holland, New York, 1986.
54. Bento JP. Man Technique Organization. Course for MTO analysis for National Board of Health and Welfare. Kurs I MTO-analys for Socialstyelesen (in Swedish). Kärnkraftsäkerhet och Utbildnings AB, Studsvik, Nyköping. (Cited in Ödergård S. From punishment to prevention? Safety Science Monitor 1999; 3: 1-10.)
55. Runciman B, Merry A, Walton A. Health care: a dysfunctional system. In: Runciman B, Merry A, Walton M. Safety and Ethics in Health Care. Ashgate, Aldershot, 2007: 59-82.
56. Light D. Psychiatry and suicide: the management of a mistake. American Sociological Review 1972; 77: 821-38.
57. Friedson E. The Profession of Medicine. Harper and Row, New York, 1970.
58. Bosk CL. Forgive and Remember: Managing Medical Failure. University of Chicago Press, Chicago, 1979.
59. Rosenthal M. The Incompetent Doctor. Open University Press, Buckingham, 1995.
60. Shaw GB. The Doctor's Dilemma. Penguin Books, London, 1946.
61. Flaubert G. Madame Bovary. Translated by Geoffrey Wall. Penguin Books, London, 1991.
62. Cronin AJ. The Citadel. Gollancz, London, 1937.
63. Hilficker D. Facing our mistakes. New England Journal of Medicine 1984; 310: 118-22
64. Horton R. We all make mistakes: tell us yours. Lancet 2001; 357: 88.
65. Cuzner E. Safety in health care. Saying sorry is not admission of liability. British Medical Journal 2008; 336: 291. Available at http://www.bmj.com/cgi/content/full/336/7639/291-b?hits=10&FIRSTINDEX=0&HITS=10&searchid=1&resourcetype=HWCIT.
66. Hobbs R. Checks and balances. Lancet 2002; 360: 254.
67. Poulter NR. Suppositions and surprises. Lancet 2001: 358: 1448.
68. Flyn G. Oh no, not again? BMJ Careers. 21 January 2006: gp27.
69. Rothman MD. The error. Yale Journal of Medical Humanities May 2003. Available at http://yjhm.yale.edu/essays/mrothman1.htm.
70. Gawande A. Complications. Picador, New York, 2002.
71. Groopman J. How Doctors Think. Houghton Mifflin Company, Boston, 2007.
72. Mercurio J. Bodies. Vintage, London, 4.
73. Bodies. http://www.bbc.co.uk/bbcthree/programmes/bodies/.
74. Welsh JM. Strong medicine and the movies: a review. Literature and Medicine 1993; 12: 111-20.
75. Smith CM. Origin and uses of Primum non Nocere - above all, do no harm! Journal of Clinical Pharmacology 2005; 45: 371-7.
76. Provonost P. The Science of Patient Safety: From Rhetoric to Reality. Video available at http://distance.jhsph.edu/trams/index.cfm?event=training.playSection§ionID=69.
77. World Health Organisation. International Classification for Patient Safety. Version 1.0 for use in field testing, 2007-2008.
78. Chang A, Schyve PM, Croteau RJ, O'Leary DS, Loeb JM. The JCAHO patient safety event taxonomy: a standardized terminology and classification schema for near misses and adverse events. International Journal for Quality in Health Care 2005; 17: 95-105.
79. World Health Organisation. Towards a Common International Understanding of Patient Safety Concepts and Terms: Taxonomy and Terminology Related to Medical Errors and System Failures. Department of Health Service Provision, World Health Organisation, Geneva, 2003.
80. Herxheimer A. Turbulence in UK medicines regulation: a stink about SSRI antidepressants that isn't going away. In: Glavanis K, O'Donovan O, eds. Power, Politics and Pharmaceuticals. Cork University Press, Cork, 2008: 171-82.
81. Medawar C, Hardon A. Medicines out of Control? Antidepressants and the Conspiracy of Goodwill. Aksant, Amsterdam, 2004.
82. Herxheimer A. Pharmacovigilance needs a complete rethink (abstract). Available at http://www.socialaudit.org.uk/6080327.htm#winners (posted 28 March 2008).
83. Lumley CE, Walker SR, Hall C, Staunton N, Grob PR. The under-reporting of adverse drug reactions seen in general practice. Pharmaceutical Medicine 1986; 1: 205-12.
84. Chalmers I. The lethal consequences of failing to make full use of all relevant evidence about the effects of medical treatments: the importance of systematic reviews. In: P. Rothwell (ed). Treating individuals: From Randomised Trials to Personalised Medicine. London: Elsevier, 2007: 37-58.
85. Medawar C, Herxheimer A. A comparison of adverse drug reaction reports from professionals and users, relating to risk of dependence and suicidal behaviour with paroxetine. International Journal of Risk and Safety in Medicine 2003/4; 16: 3-17.
86. Senders JW. My adventures as a hospital patient. Quality and Safety in Health Care 2002; 11: 365-8.
87. Agency for Healthcare Research and Quality. 20 Tips to Help Prevent Medical Errors Patient Fact Sheet. AHRQ, London, 2000. Available at http://www.ahrq.gov/consumer/20tips.htm.
88. Berntsen KJ. Fatal Care and the Patient's Guide to Preventing Medical Errors. Praeger, New York, 2004.
89. Groopman J. How Doctors Think. Houghton Mifflin Company, Boston, 2007.
90. Lyons M. Should patients have a role in patient safety? A safety engineering view. Quality and Safety in Health Care 2007; 16: 140-2.
91. Entwistle VA. Differing perspectives on patient involvement in patient safety. Quality and Safety in Health Care 2007; 16: 82-3.
92. Patients for Patient Safety, London: http://www.nc-hi.com/pdf%20files/London_Declaration_EN.pdf.
93. World Health Organisation, Patients for Patient Safety:http://www.who.int/patientsafety/patients_for_patient/en/.
94. Banja J. Medical Errors and Medical Narcissism. Jones and Bartlett Publishers, Sudbury, MA, 2005.
95. Delbanco T, Bell SK. Guilty, afraid, and alone - struggling with medical error. New England Journal of Medicine 2007; 357: 1682-3.
96. Chambers T. Framing our mistakes. In: Rubin SB, Zoloth L, eds. Margin of Error. University Publishing Group, Hagerstown, MD, 2000: 13-24.
97. Reason J. Foreword. In: Runciman W, Merry A, Walton M. Safety and Ethics in Health Care. Ashgate, Aldershot, 2007: xiv.
98. Anonymous. Scientific error. Lancet 29 January 1898: 320-2.
99. Runciman W, Merry A, Walton M. Safety and Ethics in Health Care. Ashgate, Aldershot, 2007.
100. Virilio P. The Original Accident. Polity Press, London, 2007.
101. Quoted in Tonks A. Patient safety. Safer by design. British Medical Journal 2008; 336: 186-8. Available at http://www.bmj.com/cgi/content/full/336/7637/186.
102. Lertzman R. From absent minded to error wise: a conversation with James Reason. Saferhealthcare. Available at http://www.saferhealthcare.org.uk/IHI/Topics/AnalysisandTheory/Features/AbsentMinded.htm.