Medical errors II, the aftermath: Mea culpa
By understanding that error-particularly human error-is inevitable but still largely preventable, patient safety efforts focus on improving systems, creating fail-safe mechanisms that intercept error before it reaches the bedside, and on implementing measures that mitigate harm when an error involve...
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| Published in: | Indian journal of psychiatry Vol. 53; no. 1; pp. 9 - 12 |
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| Main Authors: | , |
| Format: | Journal Article |
| Language: | English |
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India
Medknow Publications and Media Pvt. Ltd
01-01-2011
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| Abstract | By understanding that error-particularly human error-is inevitable but still largely preventable, patient safety efforts focus on improving systems, creating fail-safe mechanisms that intercept error before it reaches the bedside, and on implementing measures that mitigate harm when an error involves the patient. [7] The most common systems deficiencies identified as underlying clinical errors are failures in dissemination of drug knowledge or its updating, and inadequate availability of patient information such as test results necessary for safe treatment. |
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| AbstractList | By understanding that error-particularly human error-is inevitable but still largely preventable, patient safety efforts focus on improving systems, creating fail-safe mechanisms that intercept error before it reaches the bedside, and on implementing measures that mitigate harm when an error involves the patient. [7] The most common systems deficiencies identified as underlying clinical errors are failures in dissemination of drug knowledge or its updating, and inadequate availability of patient information such as test results necessary for safe treatment. |
| Audience | Academic |
| Author | Raguram, R Swaminath, G |
| AuthorAffiliation | Department of Psychiatry, Dr. B. R. Ambedkar Medical College, Kadugondanahalli, Bangalore - 560 045, Karnataka, India 1 Department of Psychiatry, Kempegowda Institute of Medical Sciences, Bangalore - 560004, Karnataka, India |
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| BackLink | https://www.ncbi.nlm.nih.gov/pubmed/21431001$$D View this record in MEDLINE/PubMed |
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| Cites_doi | 10.1542/pir.31.4.151 10.1056/NEJMp078104 10.4103/0019-5545.64580 10.1136/bmj.320.7237.725 10.1001/jama.2010.256 10.1001/jama.293.19.2384 10.1136/ewjm.172.6.393 10.1001/jama.1995.03530010049034 10.1097/GRF.0b013e3181899c6d 10.1097/01445442-200403000-00016 10.1097/pts.0b013e3181451606 10.1634/theoncologist.6-1-92 10.1136/bmj.320.7237.726 |
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| References_xml | – start-page: 151 year: 2010 ident: key-10.4103/0019-5545.75547-2 article-title: Patient safety and quality improvement: Medical errors and adverse events publication-title: Pediatr Rev doi: 10.1542/pir.31.4.151 contributor: fullname: Leonard – start-page: 1682 year: 2007 ident: key-10.4103/0019-5545.75547-11 article-title: Guilty, afraid, and alone - Struggling with medical error publication-title: N Engl J Med doi: 10.1056/NEJMp078104 contributor: fullname: Delbanco – start-page: 110 issn: 0019-5545 year: 2010 ident: key-10.4103/0019-5545.75547-14 article-title: Medical errors - I: The problem publication-title: Indian J Psychiatry doi: 10.4103/0019-5545.64580 contributor: fullname: Swaminath – start-page: 725 year: 2000 ident: key-10.4103/0019-5545.75547-17 article-title: Safe health care: Are we up to it? publication-title: BMJ doi: 10.1136/bmj.320.7237.725 contributor: fullname: Leape – start-page: 977 year: 2010 ident: key-10.4103/0019-5545.75547-1 article-title: Getting it right when things go wrong publication-title: JAMA doi: 10.1001/jama.2010.256 contributor: fullname: Pettker – ident: key-10.4103/0019-5545.75547-7 – start-page: 2384 year: 2005 ident: key-10.4103/0019-5545.75547-3 article-title: Five years after To Err Is Human: What have we learned? publication-title: JAMA doi: 10.1001/jama.293.19.2384 contributor: fullname: Leape – start-page: 393 year: 2000 ident: key-10.4103/0019-5545.75547-6 article-title: Human error: Models and management publication-title: West J Med doi: 10.1136/ewjm.172.6.393 contributor: fullname: Reason – start-page: 35 year: 1995 ident: key-10.4103/0019-5545.75547-8 article-title: Systems analysis of adverse drug events.ADE Prevention Study Group publication-title: JAMA doi: 10.1001/jama.1995.03530010049034 contributor: fullname: Leape – start-page: 1 year: 2010 ident: key-10.4103/0019-5545.75547-5 article-title: Responding to patient safety incidents: The "seven pillars" publication-title: Qual Saf Health Care contributor: fullname: McDonald – start-page: 700 year: 2008 ident: key-10.4103/0019-5545.75547-9 article-title: Physician error and disclosure publication-title: Clin Obstet Gynecol doi: 10.1097/GRF.0b013e3181899c6d contributor: fullname: Pelt – ident: key-10.4103/0019-5545.75547-4 doi: 10.1097/01445442-200403000-00016 – start-page: 158 year: 2007 ident: key-10.4103/0019-5545.75547-10 article-title: Disclosing unanticipated outcomes to patients: The art and practice publication-title: J Patient Saf doi: 10.1097/pts.0b013e3181451606 contributor: fullname: Gallagher – start-page: 92 year: 2001 ident: key-10.4103/0019-5545.75547-13 article-title: Medical mistakes: A workshop on personal perspectives publication-title: Oncologist doi: 10.1634/theoncologist.6-1-92 contributor: fullname: Penson – start-page: 726 year: 2000 ident: key-10.4103/0019-5545.75547-12 article-title: Medical error: The second victim.The doctor who makes the mistake needs help too publication-title: BMJ doi: 10.1136/bmj.320.7237.726 contributor: fullname: Wu – ident: key-10.4103/0019-5545.75547-15 – start-page: 13 year: 2004 ident: key-10.4103/0019-5545.75547-16 article-title: Time to learn from our mistakes? publication-title: Indian J Surg contributor: fullname: Garud |
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| Title | Medical errors II, the aftermath: Mea culpa |
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