Close calls in patient safety: Should we be paying closer attention?

CMAJ. Canadian Medical Association Journal

Volumn 185, Issue 13, 2013, Pages 1119-1120

  Wu, Albert W ^a   Marks, Clifford M ^a,b  

^a HARVARD BUSINESS SCHOOL   (United States)

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

Author keywords

[No Author keywords available]

Indexed keywords

HYDRALAZINE; HYDROXYZINE; SODIUM CHLORIDE; SUXAMETHONIUM;

ATTENTION; DIAPHRAGM PARALYSIS; DRUG LABELING; HEALTH CARE ORGANIZATION; HEALTH CARE PERSONNEL; HEALTH CARE POLICY; HUMAN; LAW SUIT; NOTE; PATIENT IDENTIFICATION; PATIENT SAFETY; ROOT CAUSE ANALYSIS;

EID: 84884539700     PISSN: 08203946     EISSN: 14882329     Source Type: Journal    
DOI: 10.1503/cmaj.130014     Document Type: Note

References (11)

1. UD, Salsman B. Medication safety: neuromuscular blocking agents. In: Wu, AW, editor. The value of close calls in improving patient safety: learning how to avoid and mitigate patient harm. Oakbrook Terrace (IL): Joint Commission Resources; 2011;77-82.
2. Wachter RM. Patient safety at ten: unmistakable progress, troubling gaps. Health Aff (Millwood) 2010;29:165-73.
3. Wu AW, Lipshutz A K M, Pronovost PJ. Effectiveness and efficiency of root cause analysis in medicine. JAMA 2008;299:685-7.
4. Barach P, Small SD. Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems. BMJ 2000;320:759-63.
5. Reason J. Human error: models and management. BMJ 2000;320:768-70.
6. Thornton RH, Miransky J, Killen AR, et al. Analysis and prioritization of near-miss adverse events in a radiology department. AJR Am J Roentgenol 2011;196:1120-4.
7. Dekker S. Discontinuity and disaster: gaps and the negotiation of culpability in medication delivery. J Law Med Ethics 2007;35:463-70.
8. Marella WM. Why worry about near misses? Patient Saf Qual Healthc 2007;4:22-6.
9. Callum JL, Kaplan HS, Merkley LL, et al. Reporting of nearmiss events for transfusion medicine: improving transfusion safety. Transfusion 2001;41:1204-11.
10. Looking at sentinel events along the continuum of patient safety: a future direction for the Sentinel Event Policy. Joint Comm Perspect 2010;30:3-5.
11. Pham JC, Kim GR, Natterman JP, et al. ReCASTing the RCA: an improved model for performing root cause analyses. Am J Med Qual 2010;25:186-91.