Journal ArticleDOI
The Critical Care Safety Study: The incidence and nature of adverse events and serious medical errors in intensive care.
Jeffrey M. Rothschild,Christopher P. Landrigan,John W. Cronin,Rainu Kaushal,Steven W. Lockley,Elisabeth Burdick,Peter Stone,Craig M. Lilly,Joel T. Katz,Charles A. Czeisler,David W. Bates +10 more
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TLDR
Adverse events and serious errors involving critically ill patients were common and often potentially life-threatening, and failure to carry out intended treatment correctly was the leading category.Abstract:
Objective: Critically ill patients require high-intensity care and may be at especially high risk of iatrogenic injury because they are severely ill. We sought to study the incidence and nature of adverse events and serious errors in the critical care setting. Design: We conducted a prospective 1-year observational study. Incidents were collected with use of a multifaceted approach including direct continuous observation. Two physicians independently assessed incident type, severity, and preventability as well as systems-related and individual performance failures. Setting: Academic, tertiary-care urban hospital. Patients Medical intensive care unit and coronary care unit patients. Interventions: None. Measurements and Main Results: The primary outcomes of interest were the incidence and rates of adverse events and serious errors per 1000 patient-days. A total of 391 patients with 420 unit admissions were studied during 1490 patient-days. We found 120 adverse events in 79 patients (20.2%), including 66 (55%) nonpreventable and 54 (45%) preventable adverse events as well as 223 serious errors. The rates per 1000 patient-days for all adverse events, preventable adverse events, and serious errors were 80.5, 36.2, and 149.7, respectively. Among adverse events, 13% (16/120) were life-threatening or fatal; and among serious errors, 11% (24/223) were potentially life-threatening. Most serious medical errors occurred during the ordering or execution of treatments, especially medications (61%; 170/277). Performance level failures were most commonly slips and lapses (53%; 148/ 277), rather than rule-based or knowledge-based mistakes. Conclusions: Adverse events and serious errors involving critically ill patients were common and often potentially life-threatening. Although many types of errors were identified, failure to carry out intended treatment correctly was the leading category. Copyright © 2005 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins.read more
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Journal ArticleDOI
Association of perceived medical errors with resident distress and empathy: a prospective longitudinal study.
Colin P. West,Mashele Huschka,Paul J. Novotny,Jeff A. Sloan,Joseph C. Kolars,Thomas M. Habermann,Tait D. Shanafelt +6 more
TL;DR: In this article, the authors assess the frequency of self-perceived medical errors among resident physicians and determine the association of perceived medical errors with resident quality of life, burnout, depression, and empathy using validated metrics.
Association of Perceived Medical Errors With Resident Distress and Empathy
Colin P. West,Mashele Huschka,Paul J. Novotny,Jeff A. Sloan,Joseph C. Kolars,Thomas M. Habermann,Tait D. Shanafelt +6 more
TL;DR: Self-perceived medical errors are common among internal medicine residents and are associated with substantial subsequent personal distress, suggesting that perceived errors and distress may be related in a reciprocal cycle.
Journal ArticleDOI
Association of Resident Fatigue and Distress With Perceived Medical Errors
TL;DR: Higher levels of fatigue and distress are independently associated with self-perceived medical errors among internal medicine residents, and sleepiness no longer had a statistically significant association with errors when adjusted for burnout or depression.
Journal ArticleDOI
Changes in Medical Errors after Implementation of a Handoff Program
Amy J. Starmer,Amy J. Starmer,Nancy D. Spector,Rajendu Srivastava,Rajendu Srivastava,Daniel C. West,Glenn Rosenbluth,April D. Allen,Elizabeth Noble,Lisa L. Tse,Anuj K. Dalal,Carol A. Keohane,Stuart R. Lipsitz,Jeffrey M. Rothschild,Matthew F. Wien,Catherine Yoon,Katherine R. Zigmont,Karen M. Wilson,Jennifer K. O'Toole,Lauren G. Solan,Megan Aylor,Zia Bismilla,Maitreya Coffey,Sanjay Mahant,Rebecca Blankenburg,Lauren Destino,Jennifer L. Everhart,Shilpa J. Patel,Shilpa J. Patel,James F. Bale,Jaime Blank Spackman,Adam Stevenson,Sharon Calaman,F. Sessions Cole,Dorene F. Balmer,Jennifer Hepps,Joseph O. Lopreiato,Clifton E. Yu,Theodore C. Sectish,Christopher P. Landrigan +39 more
TL;DR: Implementation of the handoff program was associated with reductions in medical errors and in preventable adverse events and with improvements in communication, without a negative effect on workflow.
Journal ArticleDOI
Drug-related problems in hospitals: a review of the recent literature.
Anita Krähenbühl-Melcher,Raymond G. Schlienger,Markus L. Lampert,Manuel Haschke,Jürgen Drewe,Stephan Krähenbühl +5 more
TL;DR: Analysis of original publications published between 1990 and 2005 on the topics of medication errors and/or adverse drug events in hospitalised patients, focusing on the frequency of, risk factors for and avoidance of such problems associated with pharmacotherapy, indicated that medication errors occurred in a mean of 5.7% of all episodes of drug administration, but with a high variability among the 35 studies retrieved.
References
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BookDOI
To Err Is Human Building a Safer Health System
TL;DR: Boken presenterer en helhetlig strategi for hvordan myndigheter, helsepersonell, industri og forbrukere kan redusere medisinske feil.
Journal ArticleDOI
APACHE II: a severity of disease classification system.
TL;DR: The form and validation results of APACHE II, a severity of disease classification system that uses a point score based upon initial values of 12 routine physiologic measurements, age, and previous health status, are presented.
Journal ArticleDOI
APACHE II-A Severity of Disease Classification System: Reply
TL;DR: The form and validation results of APACHE II, a severity of disease classification system, are presented, showing an increasing score was closely correlated with the subsequent risk of hospital death for 5815 intensive care admissions from 13 hospitals.
Journal ArticleDOI
Human error: models and management
TL;DR: The longstanding and widespread tradition of the person approach focuses on the unsafe acts—errors and procedural violations—of people at the sharp end: nurses, physicians, surgeons, anaesthetists, pharmacists, and the like.
Journal ArticleDOI
Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I.
Troyen A. Brennan,Lucian L. Leape,Nan M. Laird,Liesi E. Hebert,A R Localio,Ann G. Lawthers,Joseph P. Newhouse,Paul C. Weiler,Howard H. Hiatt +8 more
TL;DR: There is a substantial amount of injury to patients from medical management, and many injuries are the result of substandard care.