« Previous
Next »
Annals of Emergency Medicine
Volume 51, Issue 3
, Pages 251-261.e1
, March 2008
Characteristics of Patient Care Management Problems Identified in Emergency Department Morbidity and Mortality Investigations During 15 Years
References
- Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study I. N Engl J Med. 1991;324:370–376
- The nature of adverse events in hospitalized patients: results of the Harvard Medical Practice Study II. N Engl J Med. 1991;324:377–384
- Incidence and types of adverse events and negligent care in Utah and Colorado. Med Care. 2000;38:261–271
- The Quality in Australian Health Care Study. Med J Aust. 1995;163:458–471
- . Adverse events in British hospitals: preliminary retrospective record review. BMJ. 2001;322:517–519
- Ottawa Hospital Patient Safety Study: incidence and timing of adverse events in patients admitted to a Canadian teaching hospital. CMAJ. 2004;170:1235–1240
- In: Kohn LT, Corrigan JM, Donaldson MS editor. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000;
- . Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001;
- . Patient Safety and Quality Improvement Act of 2005. Ann Pharmacother. 2006;40:917–924
- . Making patient safety the centerpiece of medical liability reform. N Engl J Med. 2006;354:2205–2208
- Effect of reducing interns’ work hours on serious medical errors in intensive care units. N Engl J Med. 2004;351:1838–1848
- . Patient safety: a curriculum for teaching patient safety in emergency medicine. Acad Emerg Med. 2003;10:69–78
- . Emergency medicine: a practice prone to error?. Can J Emerg Med. 2001;3:271–276
- . Hospital-Based Emergency Care: At the Breaking Point. Washington, DC: National Academies Press; 2006;
- . A framework for classifying factors that contribute to error in the emergency department. Ann Emerg Med. 2003;42:815–823
- . Framework for analysing risk and safety in clinical medicine. BMJ. 1998;316:1154–1157
- . Human Error. Cambridge, England: Cambridge University Press; 1990;
- . Diagnostic failure: a cognitive and affective approach. In: Henriksen K, Battles JB, Marks ES, et al. editor. Advances in Patient Safety: From Research to Implementation. Vol 2:Rockville, MD: Agency for Healthcare Research and Quality; 2005;p. 241–254AHRQ Publication No. 05-0021-2
- . Effect of outcome on physician judgments of the appropriateness of care. JAMA. 1991;265:1957–1960
- . Hindsight bias, outcome knowledge and adaptive learning. Qual Saf Health Care. 2003;12(suppl II):ii46–ii50
- . Human Error (Cause, Prediction, and Reduction): Analysis and Synthesis. Hillsdale, NJ: Lawrence Erlbaum Associates, Inc; 1991;
- A string of mistakes: the importance of cascade analysis in describing, counting, and preventing medical errors. Ann Fam Med. 2004;2:317–326
- . Diagnostic errors. Acad Emerg Med. 2002;9:740–750
- Diagnosing diagnostic errors: lessons from a multi-institutional collaborative project. In: Henriksen K, Battles JB, Marks ES, et al. editor. Advances in Patient Safety: From Research to Implementation. Vol 2:Rockville, MD: Agency for Healthcare Research and Quality; 2005;p. 255–278AHRQ Publication No. 05-0021-2
- . Achilles heels of the ED: delayed or missed diagnoses. ED Leg Lett. 2003;14:109–120
- Prevalence of information gaps in the emergency department and the effect on patient outcomes. CMAJ. 2003;169:1023–1028
- . Team communication in the operating room. Acta Anaesthesiol Scand. 2005;49:898–901
- Decline in ICU adverse events, nosocomial infections and cost through a quality improvement initiative focusing on teamwork and culture change. Qual Saf Health Care. 2006;15:235–239
- A conceptual framework for studying the safety of transitions in emergency care. In: Henriksen K, Battles JB, Marks ES, et al. editor. Advances in Patient Safety: From Research to Implementation. Vol 2:Rockville, MD: Agency for Healthcare Research and Quality; 2005;p. 309–3321AHRQ Publication No. 05-0021-2
- . Achieving quality in clinical decision making: cognitive strategies and detection of bias. Acad Emerg Med. 2002;9:1184–1204
- . The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med. 2003;78:775–780
- . Cognitive forcing strategies in clinical decisionmaking. Ann Emerg Med. 2003;41:110–120
- . The cognitive imperative: thinking about how we think. Acad Emerg Med. 2000;7:1223–1231
- . Metacognitive training to reduce diagnostic errors: ready for prime time?. Acad Med. 2003;78:781
- . Clinical problem solving and diagnostic decision making: selective review of the cognitive literature. BMJ. 2002;324:729–732
- . Learning Clinical Reasoning. Baltimore, MD: Williams & Wilkins; 1991;
- . Reducing diagnostic errors in medicine: what’s the goal?. Acad Med. 2002;77:981–992
- . Diagnostic error in internal medicine. Arch Intern Med. 2005;165:1493–1499
- Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: a systematic review. JAMA. 2005;293:1223–1238
- Ten commandments for effective clinical decision support: making the practice of evidence-based medicine a reality. J Am Med Inform Assoc. 2003;10:523–530
- Using simulation to instruct emergency medicine residents in cognitive forcing strategies. Acad Med. 2004;79:438–446
- . How to investigate and analyse clinical incidents: Clinical Risk Management and Association of Litigation and Risk Management protocol. BMJ. 2000;320:777–781
- . Cognitive errors in diagnosis: instantiation, classification, and consequences. Am J Med. 1989;86:433–441
- Redesigning health systems for quality: lessons from emerging practices. Jt Comm J Qual Patient Saf. 2006;32:599–611
- . The intuitive psychologist and his shortcomings: distortions in the attribution process. In: Berkowitz L editors. Advances in Experimental Social Psychology. New York, NY: Academic Press; 1977;p. 174–221
- . Medical Errors and Medical Narcissism. Sudbury, MA: Jones and Bartlett Publishers; 2005;
- . Organizational change in the face of highly public errors (I. The Dana-Farber Cancer Institute experience). Accessed January 26, 2007 http://www.webmm.ahrq.gov/perspective.aspx?perspectiveID=3
- Missed and delayed diagnoses in the emergency department: a study of closed malpractice claims from 4 liability insurers. Ann Emerg Med. 2007;49:196–205
- Cause-and-effect analysis of risk management files to assess patient care in the emergency department. Acad Emerg Med. 2004;11:1035–1041
Supervising editor: Robert L. Wears, MD, MSAuthor contributions: KSC and RR conceived the study and obtained funding. KSC, RR, JS, and RDS designed the study. KSC, LP, CR, JS, S Sherman, IN, EC, ML, and S Schabowski were responsible for data acquisition. KSC, RR, IA, and RDS analyzed and interpreted the data. KSC and RR drafted the article and all authors contributed substantially to its revision. KSC, RR, IA, and RDS were responsible for statistical analysis. RR, LP, CR, JS, S Sherman, IN, EC, ML, S Schabowski, IA, and RDS provided administrative, technical, or material support. KSC and RR were responsible for overall study supervision. KSC and RR had full access to all the data and take responsibility for the integrity of the data and the accuracy of the data analysis. KSC takes responsibility for the paper as a whole.Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article, that might create any potential conflict of interest. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement. This study was funded in part by the Agency for Healthcare Research and Quality, grant number 5 P20 HS011552, and the Department of Emergency Medicine, Cook County Hospital (Stroger).Publication date: Available online October 15, 2007.
PII: S0196-0644(07)01252-8
doi: 10.1016/j.annemergmed.2007.06.483
© 2008 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.
« Previous
Next »
Annals of Emergency Medicine
Volume 51, Issue 3
, Pages 251-261.e1
, March 2008
