Medical Errors

Publication Title: 
Journal for Healthcare Quality: Official Publication of the National Association for Healthcare Quality

This article describes a knowledge-transfer process developed by Catholic Health East (CHE), headquartered in Newtown Square, PA, and focuses on improving resident safety in the skilled nursing or long-term care setting. How the health system customized and implemented an electronic medical event database to identify opportunities for improvement to prevent future occurrences of adverse events is outlined.

Carroll-Solomon, Pamela A.
Denny, Diane S.
Publication Title: 
Joint Commission Journal on Quality and Patient Safety

BACKGROUND: For Ascension Health's Healthcare That Is Safe strategy, Sacred Heart Hospital (SHH) and Columbia St. Mary's (CSM) served as alpha sites to develop strategies to eliminate perioperative adverse events (POAEs). The alpha sites set an interim goal of a 50% reduction of POAEs, then 100%, or elimination of POAEs by July 2008.

Ewing, Hella
Bruder, Greg
Baroco, Paul
Hill, Maria
Sparkman, Lora P.
Publication Title: 
Health Affairs (Project Hope)

Communicating openly and honestly with patients and families about unexpected medical events-a policy known as full disclosure-improves outcomes for patients and providers. Although many certification and licensing organizations have declared full disclosure to be imperative, the adoption of and adherence to a full disclosure protocol is not common practice in most clinical settings. We conducted a case study of Ascension Health's implementation of a full disclosure protocol at five labor and delivery demonstration sites.

Hendrich, Ann
McCoy, Christine Kocot
Gale, Jane
Sparkman, Lora
Santos, Palmira
Publication Title: 
BMC health services research

BACKGROUND: A common finding in several studies is patients' dissatisfaction with complaint handling in health care. The reasons why are for the greater part unknown. The key to an answer may be found in a better understanding of patients' expectations. We investigated patients' expectations of complaint handling in hospitals. METHODS: Subjects were patients who had lodged a complaint at the complaint committees of 74 hospitals in the Netherlands. A total of 424 patients (response 75%) completed a written questionnaire at the start of the complaint procedures.

Friele, Roland D.
Sluijs, Emmy M.
Publication Title: 
Postgraduate Medical Journal

AIM: To determine whether analysis of unsolicited healthcare complaints specifically focusing on unprofessional behaviour can provide additional information from the patients' perspective. METHODS: A qualitative study with content analysis of healthcare complaints and associated judgements using complaints filed from 2004 to 2009 at the complaints committee of a tertiary-referral centre. Subsequent comparison of the resulting categories of poor professionalism to categories perceived relevant by physicians in a previous study was performed.

van Mook, Walther N. K. A.
Gorter, Simone L.
Kieboom, Wendy
Castermans, Miem G. T. H.
de Feijter, Jeantine
de Grave, Willem S.
Zwaveling, Jan Harm
Schuwirth, Lambert W. T.
van der Vleuten, Cees P. M.
Publication Title: 
Homeopathy: The Journal of the Faculty of Homeopathy

BACKGROUND: The assessment of harm arising from the use of homeopathic medicine is much discussed, but there is little published data on the subject. AIM: To study prospectively adverse drug events related to homeopathic medicines. SETTING: The data were gathered between 1 June 2003 and 30 June 2004 during follow-up visits consecutively carried out at the Homeopathic Clinic, Campo di Marte Hospital, Azienda USL 2, Lucca (Italy). They refer to effects following the administration of a homeopathic medicine, prescribed according to the classical homeopathic method.

Endrizzi, C.
Rossi, E.
Crudeli, L.
Garibaldi, D.
Publication Title: 
Journal of Manipulative and Physiological Therapeutics

OBJECTIVE: The objective of this review is to develop an evidence-focused and work-based model framework for patient safety training, that is, reporting and learning from adverse events in chiropractic care. This article will not debate specific issues of adverse events from spinal manipulation. The main focus is on education for patient safety. METHODS: We conducted a systematic search and synthesized 196 articles on patient safety to provide guidance.

Zaugg, Beatrice
Wangler, Martin
Publication Title: 
Australian Journal of Primary Health

This paper reports on an investigation into five risk prevention factors (technology, people, organisational structure, culture and top management psychology) to inform organisational preparedness planning and to update managers on the state of health care services. Data were collected by means of a 10-question, cross-sectional survey of key decision-making executives in eight different types of 75 health care organisations. Many organisations were found to have deficient risk prevention practices and allied health organisations were considerably worse than health organisations.

Canyon, Deon V.
Publication Title: 
Acupuncture in Medicine: Journal of the British Medical Acupuncture Society

Everyone wants safe medicine. The traditional approach to adverse events has developed within a culture of blaming the individual practitioner. Such an approach is likely to be damaging to individuals and possibly counterproductive by creating an atmosphere of defensiveness and denial. Industries such as airlines have developed an alternative culture using a systems approach. This approach concentrates on assessing and improving the systems of working rather than blaming an individual's performance.

White, Adrian
Publication Title: 
Zhong Xi Yi Jie He Xue Bao = Journal of Chinese Integrative Medicine

Acupuncture is widely used as an alternative therapy with few side effects because of its simple manipulation and low cost. However, accidents may occur if the practitioner uses it improperly. Early in the Qin dynasty, the Canon of Medicine mentioned that improper use of acupuncture could cause injury to the body and even death, and it systematically described the occurrence and prevention of acupuncture accidents.

Zhang, Ren


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