medical errors

Summary

Summary: Errors or mistakes committed by health professionals which result in harm to the patient. They include errors in diagnosis (DIAGNOSTIC ERRORS), errors in the administration of drugs and other medications (MEDICATION ERRORS), errors in the performance of surgical procedures, in the use of other types of therapy, in the use of equipment, and in the interpretation of laboratory findings. Medical errors are differentiated from MALPRACTICE in that the former are regarded as honest mistakes or accidents while the latter is the result of negligence, reprehensible ignorance, or criminal intent.

Top Publications

  1. ncbi Errors in a stat laboratory: types and frequencies 10 years later
    Paolo Carraro
    Department of Laboratory Medicine, Azienda Ospedaliera Università and Azienda ULSS 16, Padova, Italy
    Clin Chem 53:1338-42. 2007
  2. ncbi A survey on patient safety culture in primary healthcare services in Turkey
    Said Bodur
    Department of Public Health, Selcuk University, Konya, Turkey
    Int J Qual Health Care 21:348-55. 2009
  3. ncbi AHRQ's hospital survey on patient safety culture: psychometric analyses
    Mary A Blegen
    Community Health Systems Department, School of Nursing, University of California, San Francisco, CA 94143, USA
    J Patient Saf 5:139-44. 2009
  4. ncbi Burnout and medical errors among American surgeons
    Tait D Shanafelt
    Department of Internal Medicine, Division of Hematology, Mayo Clinic, Rochester, MN 55905, USA
    Ann Surg 251:995-1000. 2010
  5. pmc The incidence and nature of in-hospital adverse events: a systematic review
    E N de Vries
    Department of Surgery, Academic Medical Centre, University of Amsterdam, The Netherlands
    Qual Saf Health Care 17:216-23. 2008
  6. ncbi Association of perceived medical errors with resident distress and empathy: a prospective longitudinal study
    Colin P West
    Division of General Internal Medicine, Department of Medicine, Mayo Clinic College of Medicine, Rochester, Minn 55905, USA
    JAMA 296:1071-8. 2006
  7. ncbi Temporal trends in rates of patient harm resulting from medical care
    Christopher P Landrigan
    Division of Sleep Medicine, Department of Medicine, Brigham and Women s Hospital and Harvard Medical, Boston, MA 02115, USA
    N Engl J Med 363:2124-34. 2010
  8. ncbi Incidence and types of adverse events and negligent care in Utah and Colorado
    E J Thomas
    Department of Medicine, Brigham and Women s Hospital, Boston, Massachusetts, USA
    Med Care 38:261-71. 2000
  9. ncbi Association of resident fatigue and distress with perceived medical errors
    Colin P West
    Division of General Internal Medicine, Department of Medicine, Mayo Clinic, 200 First St, SW, Rochester, MN 55905, USA
    JAMA 302:1294-300. 2009
  10. pmc The human factor: the critical importance of effective teamwork and communication in providing safe care
    M Leonard
    Colorado Permanente Medical Group, Denver, USA
    Qual Saf Health Care 13:i85-90. 2004

Detail Information

Publications306 found, 100 shown here

  1. ncbi Errors in a stat laboratory: types and frequencies 10 years later
    Paolo Carraro
    Department of Laboratory Medicine, Azienda Ospedaliera Università and Azienda ULSS 16, Padova, Italy
    Clin Chem 53:1338-42. 2007
    ....
  2. ncbi A survey on patient safety culture in primary healthcare services in Turkey
    Said Bodur
    Department of Public Health, Selcuk University, Konya, Turkey
    Int J Qual Health Care 21:348-55. 2009
    ..To evaluate the patient safety culture in primary healthcare units...
  3. ncbi AHRQ's hospital survey on patient safety culture: psychometric analyses
    Mary A Blegen
    Community Health Systems Department, School of Nursing, University of California, San Francisco, CA 94143, USA
    J Patient Saf 5:139-44. 2009
    ....
  4. ncbi Burnout and medical errors among American surgeons
    Tait D Shanafelt
    Department of Internal Medicine, Division of Hematology, Mayo Clinic, Rochester, MN 55905, USA
    Ann Surg 251:995-1000. 2010
    To evaluate the relationship between burnout and perceived major medical errors among American surgeons.
  5. pmc The incidence and nature of in-hospital adverse events: a systematic review
    E N de Vries
    Department of Surgery, Academic Medical Centre, University of Amsterdam, The Netherlands
    Qual Saf Health Care 17:216-23. 2008
    ..Many studies have been conducted to gain an insight into this problem, but a general overview of the data is lacking. We performed a systematic review of the literature on in-hospital adverse events...
  6. ncbi Association of perceived medical errors with resident distress and empathy: a prospective longitudinal study
    Colin P West
    Division of General Internal Medicine, Department of Medicine, Mayo Clinic College of Medicine, Rochester, Minn 55905, USA
    JAMA 296:1071-8. 2006
    b>Medical errors are associated with feelings of distress in physicians, but little is known about the magnitude and direction of these associations.
  7. ncbi Temporal trends in rates of patient harm resulting from medical care
    Christopher P Landrigan
    Division of Sleep Medicine, Department of Medicine, Brigham and Women s Hospital and Harvard Medical, Boston, MA 02115, USA
    N Engl J Med 363:2124-34. 2010
    ..In the 10 years since publication of the Institute of Medicine's report To Err Is Human, extensive efforts have been undertaken to improve patient safety. The success of these efforts remains unclear...
  8. ncbi Incidence and types of adverse events and negligent care in Utah and Colorado
    E J Thomas
    Department of Medicine, Brigham and Women s Hospital, Boston, Massachusetts, USA
    Med Care 38:261-71. 2000
    ..The generalizability of these findings is unknown and has been questioned by other studies...
  9. ncbi Association of resident fatigue and distress with perceived medical errors
    Colin P West
    Division of General Internal Medicine, Department of Medicine, Mayo Clinic, 200 First St, SW, Rochester, MN 55905, USA
    JAMA 302:1294-300. 2009
    Fatigue and distress have been separately shown to be associated with medical errors. The contribution of each factor when assessed simultaneously is unknown.
  10. pmc The human factor: the critical importance of effective teamwork and communication in providing safe care
    M Leonard
    Colorado Permanente Medical Group, Denver, USA
    Qual Saf Health Care 13:i85-90. 2004
    ....
  11. pmc Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study I. 1991
    T A Brennan
    Division of General Medicine, Brigham and Women s Hospital and Harvard Medical School, Boston, Massachusetts, USA
    Qual Saf Health Care 13:145-51; discussion 151-2. 2004
    ....
  12. ncbi Effect of reducing interns' work hours on serious medical errors in intensive care units
    Christopher P Landrigan
    Division of Sleep Medicine, Brigham and Women s Hospital, Boston, MA 02115, USA
    N Engl J Med 351:1838-48. 2004
    Although sleep deprivation has been shown to impair neurobehavioral performance, few studies have measured its effects on medical errors.
  13. pmc The psychometric properties of the 'Hospital Survey on Patient Safety Culture' in Dutch hospitals
    Marleen Smits
    NIVEL, Netherlands Institute for Health Services Research, PO Box 1568, 3500 BN Utrecht, The Netherlands
    BMC Health Serv Res 8:230. 2008
    ..The aim of this study was to examine the underlying dimensions and psychometric properties of the questionnaire in Dutch hospital settings, and to compare these results with the original questionnaire used in USA hospital settings...
  14. pmc Sensitivity of routine system for reporting patient safety incidents in an NHS hospital: retrospective patient case note review
    Ali Baba Akbari Sari
    Department of Health Sciences, University of York, York YO10 5DD
    BMJ 334:79. 2007
    ..To evaluate the performance of a routine incident reporting system in identifying patient safety incidents...
  15. pmc The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada
    G Ross Baker
    Department of Health Policy, Management and Evaluation, University of Toronto, McMurrich Building Room 2031, 12 Queen s Park Crescent West, Toronto, Ontario M5S 1A8, Canada
    CMAJ 170:1678-86. 2004
    ..AEs are unintended injuries or complications resulting in death, disability or prolonged hospital stay that arise from health care management. We estimated the incidence of AEs among patients in Canadian acute care hospitals...
  16. pmc Safety culture assessment: a tool for improving patient safety in healthcare organizations
    V F Nieva
    Westat, Research Blvd, Rockville, MD 20850, USA
    Qual Saf Health Care 12:ii17-23. 2003
    ..The paper also highlights critical processes that healthcare organizations need to consider when deciding to use these tools...
  17. pmc Towards an International Classification for Patient Safety: the conceptual framework
    Heather Sherman
    Department of Health Services Research, Division of Quality Measurement and Research, The Joint Commission, One Rennaisance Blvd, Oakbrook Terrace, IL 60181 USA
    Int J Qual Health Care 21:2-8. 2009
    ..Concepts need to be defined, guidance for using the classification needs to be provided, and further real-world testing needs to occur to progressively refine the ICPS to ensure it is fit for purpose...
  18. ncbi Critical incident reporting and learning
    R P Mahajan
    Division of Anaesthesia and Intensive Care, Queen s Medical Centre, Nottingham NG7 2UH, UK
    Br J Anaesth 105:69-75. 2010
    ....
  19. pmc Ottawa Hospital Patient Safety Study: incidence and timing of adverse events in patients admitted to a Canadian teaching hospital
    Alan J Forster
    Ottawa Health Research Institute, Ottawa, Ont
    CMAJ 170:1235-40. 2004
    ..We evaluated characteristics of adverse events affecting patients admitted to a Canadian teaching hospital, paying particular attention to timing...
  20. pmc Adverse events in British hospitals: preliminary retrospective record review
    C Vincent
    Clinical Risk Unit, Department of Psychology, University College London, London WC1E 6BT, UK
    BMJ 322:517-9. 2001
    ..To examine the feasibility of detecting adverse events through record review in British hospitals and to make preliminary estimates of the incidence and costs of adverse events...
  21. pmc The incidence of adverse events in Swedish hospitals: a retrospective medical record review study
    Michael Soop
    Department for Supervision of Healthcare Services, National Board of Health and Welfare, 10630 Stockholm, Sweden
    Int J Qual Health Care 21:285-91. 2009
    ..To estimate the incidence, nature and consequences of adverse events and preventable adverse events in Swedish hospitals...
  22. pmc Communication failures in the operating room: an observational classification of recurrent types and effects
    L Lingard
    University of Toronto, Toronto, Ontario, Canada
    Qual Saf Health Care 13:330-4. 2004
    ..This study was part of a larger project to develop a team checklist to improve communication in the OR...
  23. ncbi Views of practicing physicians and the public on medical errors
    Robert J Blendon
    Department of Health Policy and Management, Harvard School of Public Health, Boston 02115, USA
    N Engl J Med 347:1933-40. 2002
    In response to the report by the Institute of Medicine on medical errors, national groups have recommended actions to reduce the occurrence of preventable medical errors...
  24. ncbi Medical errors in orthopaedics. Results of an AAOS member survey
    David A Wong
    Denver Spine, Suite 100, 7800 East Orchard Road, Greenwood Village, CO 80111, USA
    J Bone Joint Surg Am 91:547-57. 2009
    There has been widespread interest in medical errors since the publication of To Err Is Human: Building a Safer Health System by the Institute of Medicine in 2000...
  25. ncbi Selected medical errors in the intensive care unit: results of the IATROREF study: parts I and II
    Maite Garrouste-Orgeas
    Service de Réanimation medico chirurgicale, Groupe Hospitalier Paris Saint Joseph, 185 rue Raymond Losserand, 75014 Paris, France
    Am J Respir Crit Care Med 181:134-42. 2010
    ..Identifying medical errors (MEs) that serve as indicators for iatrogenic risk is crucial for purposes of reporting and prevention.
  26. ncbi Analysis of errors reported by surgeons at three teaching hospitals
    Atul A Gawande
    Brigham and Women s Hospital and Harvard School of Public Health, Boston, MA 02155, USA
    Surgery 133:614-21. 2003
    Little is known of the factors that underlie surgical errors. Incident reporting has been proposed as a method of obtaining information about medical errors to help identify such factors.
  27. ncbi The checklist--a tool for error management and performance improvement
    Brigette M Hales
    Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada M4N 3M5
    J Crit Care 21:231-5. 2006
    ..This narrative is a guide to the evolution of medical and critical care checklists, and a discussion of the barriers and risks to the implementation of checklists...
  28. ncbi Adverse events and potentially preventable deaths in Dutch hospitals: results of a retrospective patient record review study
    M Zegers
    NIVEL, Netherlands Institute for Health Services Research, Utrecht, The Netherlands
    Qual Saf Health Care 18:297-302. 2009
    ..This study determined the incidence, type, nature, preventability and impact of adverse events (AEs) among hospitalised patients and potentially preventable deaths in Dutch hospitals...
  29. pmc What can hospitalized patients tell us about adverse events? Learning from patient-reported incidents
    Saul N Weingart
    Center for Patient Safety, Dana Farber Cancer Institute, Boston, MA 02115, USA
    J Gen Intern Med 20:830-6. 2005
    ..Accordingly, the purpose of this study was to elicit incident reports from hospital inpatients in order to identify and characterize adverse events and near-miss errors...
  30. ncbi The nature of safety problems among Canadian homecare clients: evidence from the RAI-HC reporting system
    Diane M Doran
    Lawrence S Bloomberg Faculty of Nursing, University of Toronto, 155 College Street, Toronto, Ontario, Canada
    J Nurs Manag 17:165-74. 2009
    ..The purpose of this study was to identify the nature of patient safety problems among Canadian homecare (HC) clients, using data collected through the RAI-HC((c)) assessment instrument...
  31. ncbi Communication failures: an insidious contributor to medical mishaps
    Kathleen M Sutcliffe
    University of Michigan Business School, Ann Arbor, Michigan 48109 1334, USA
    Acad Med 79:186-94. 2004
    ..To describe how communication failures contribute to many medical mishaps...
  32. ncbi A description of adverse events in home healthcare
    Elizabeth A Madigan
    Case Western Reserve University, Cleveland, Ohio 44106 4904, USA
    Home Healthc Nurse 25:191-7. 2007
    ..The findings also raise questions regarding the appropriateness of these adverse events and whether there are additional adverse events that warrant monitoring and follow-up evaluation...
  33. pmc Measuring errors and adverse events in health care
    Eric J Thomas
    The Center for Clinical Research and Evidence Based Medicine, Division of General Medicine, and Department of Medicine at The University of Texas Houston Medical School, 77030, USA
    J Gen Intern Med 18:61-7. 2003
    ..We propose a general framework to help health care providers, researchers, and administrators choose the most appropriate methods to meet their patient safety measurement goals...
  34. pmc A comprehensive overview of medical error in hospitals using incident-reporting systems, patient complaints and chart review of inpatient deaths
    Jeantine M de Feijter
    Department of Educational Development and Research, Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
    PLoS ONE 7:e31125. 2012
    Incident reporting systems (IRS) are used to identify medical errors in order to learn from mistakes and improve patient safety in hospitals. However, IRS contain only a small fraction of occurring incidents...
  35. ncbi Patient safety in developing countries: retrospective estimation of scale and nature of harm to patients in hospital
    R M Wilson
    New York City Health and Hospital Corporation, 125 Worth Street, New York, NY 10013, USA
    BMJ 344:e832. 2012
    ..To assess the frequency and nature of adverse events to patients in selected hospitals in developing or transitional economies...
  36. ncbi Avoiding wrong site surgery: a systematic review
    John Devine
    Orthopedic Service, Department of Surgery, Eisenhower Army Medical Center, Ft Gordon, GA 30809, USA
    Spine (Phila Pa 1976) 35:S28-36. 2010
    ..Systematic review...
  37. ncbi Medical errors and complaints in emergency department care in Sweden as reported by care providers, healthcare staff, and patients - a national review
    Ann Sofie Källberg
    Department of Emergency Medicine, Falun Hospital, Falun, Sweden
    Eur J Emerg Med 20:33-8. 2013
    ..The aim of this study was therefore to describe the incidence and types of reported medical errors and complaints in ED care in Sweden.
  38. ncbi Integrating incident data from five reporting systems to assess patient safety: making sense of the elephant
    Osnat Levtzion-Korach
    Division of General Internal Medicine, Brigham and Women s Hospital, Boston, USA
    Jt Comm J Qual Patient Saf 36:402-10. 2010
    ..These data sources vary in the timing of the reporting (retrospective or prospective), severity of the events, and profession of the reporters...
  39. ncbi Mistakes in a stat laboratory: types and frequency
    M Plebani
    Servizio di Medicina di Laboratorio, Azienda Ospedaliera di Padova, Italy
    Clin Chem 43:1348-51. 1997
    ..The promotion of quality control and continuous improvement of the total testing process, including pre- and postanalytical phases, seems to be a prerequisite for an effective laboratory service...
  40. ncbi Adverse events among patients registered in high-acuity areas of the emergency department: a prospective cohort study
    Lisa Anne Calder
    Department of Emergency Medicine, University of Ottawa, Ontario, Canada
    CJEM 12:421-30. 2010
    ..We performed this study to describe the types and risk of adverse events in high-acuity areas of the emergency department (ED)...
  41. pmc Patient safety: what about the patient?
    C A Vincent
    Clinical Risk Unit, Department of Psychology, University College London, London WC1E 6BT, UK
    Qual Saf Health Care 11:76-80. 2002
    ....
  42. pmc Impact of inadequate empirical therapy on the mortality of patients with bloodstream infections: a propensity score-based analysis
    Pilar Retamar
    Unidad Clínica de Enfermedades Infecciosas y Microbiología, Hospital Universitario Virgen Macarena, Seville, Spain
    Antimicrob Agents Chemother 56:472-8. 2012
    ..Programs to improve the quality of empirical therapy in patients with suspicion of BSI and optimization of definitive therapy should be implemented...
  43. pmc Incident reporting and patient safety
    Charles Vincent
    BMJ 334:51. 2007
  44. pmc An analysis of computer-related patient safety incidents to inform the development of a classification
    Farah Magrabi
    Centre for Health Informatics, University of New South Wales, Sydney, Australia
    J Am Med Inform Assoc 17:663-70. 2010
    ..To analyze patient safety incidents associated with computer use to develop the basis for a classification of problems reported by health professionals...
  45. ncbi Reporting of adverse events
    Lucian L Leape
    Harvard School of Public Health, Boston, USA
    N Engl J Med 347:1633-8. 2002
  46. pmc To what extent are adverse events found in patient records reported by patients and healthcare professionals via complaints, claims and incident reports?
    Ingrid Christiaans-Dingelhoff
    EMGO Institute for Health and Care Research, Department of Public and Occupational Health, VU University Medical Center, Amsterdam, The Netherlands
    BMC Health Serv Res 11:49. 2011
    ..The aim of the study is to examine to what extent the hospital reporting systems cover the adverse events identified by patient record review...
  47. ncbi Application of the human factors analysis and classification system methodology to the cardiovascular surgery operating room
    Andrew W ElBardissi
    Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota 55905, USA
    Ann Thorac Surg 83:1412-8; discussion 1418-9. 2007
    ..We hypothesized that human factors identified in other domains would similarly be viewed as contributors to error in cardiac surgery...
  48. ncbi Establishing a global learning community for incident-reporting systems
    Julius Cuong Pham
    The Johns Hopkins University School of Medicine, 1909 Thames Street, 2nd Floor, Baltimore, MD 21231, USA
    Qual Saf Health Care 19:446-51. 2010
    ..Compared with systems in other high-risk industries, healthcare IRS are fragmented and isolated, and have not established best practices for implementation and utilisation...
  49. pmc Measuring patient safety culture in Taiwan using the Hospital Survey on Patient Safety Culture (HSOPSC)
    I Chi Chen
    College of Management, Yuan Ze University, Taoyuan, Taiwan
    BMC Health Serv Res 10:152. 2010
    ....
  50. ncbi Is the "International Classification for Patient Safety" a classification?
    Stefan Schulz
    IMBI, University Medical Center, 79104 Freiburg, Germany
    Stud Health Technol Inform 150:502-6. 2009
    ..Acknowledging its merits as a standard reporting instrument for change management and process improvements we propose formal improvements...
  51. ncbi Testing process errors and their harms and consequences reported from family medicine practices: a study of the American Academy of Family Physicians National Research Network
    J Hickner
    Department of Family Medicine, The University of Chicago Pritzker School of Medicine, 5841 S Maryland Ave, MC 7110, Suite M 156, Chicago, IL 60637 1470, USA
    Qual Saf Health Care 17:194-200. 2008
    ..Little is known about the types and outcomes of testing process errors that occur in primary care...
  52. ncbi Psychometric properties of the Hospital Survey on Patient Safety Culture: findings from the UK
    P Waterson
    Department of Human Sciences, Loughborough University, Loughborough LE11 3TU, UK
    Qual Saf Health Care 19:e2. 2010
    ..This study reports an assessment of the psychometric properties and suitability of the American Hospital Survey on Patient Safety Culture for use within the UK...
  53. ncbi Using usability heuristics to evaluate patient safety of medical devices
    Jiajie Zhang
    School of Health Information Sciences, University of Texas Health Science Center at Houston, 7000 Fannin, Suite 600, Houston, TX 77030, USA
    J Biomed Inform 36:23-30. 2003
    ....
  54. ncbi A framework for classifying factors that contribute to error in the emergency department
    Karen S Cosby
    Department of Emergency Medicine, Stroger Hospital of Cook County Rush Medical College, Chicago, IL 60612, USA
    Ann Emerg Med 42:815-23. 2003
    ..It incorporates ideas found in safety engineering, transportation safety, human factors engineering, and our own experience in an urban, public, teaching hospital ED...
  55. ncbi Frequency of failure to inform patients of clinically significant outpatient test results
    Lawrence P Casalino
    Department of Public Health, Weill Cornell Medical College, New York, NY 10065 6304, USA
    Arch Intern Med 169:1123-9. 2009
    ..Failing to inform a patient of an abnormal outpatient test result can be a serious error, but little is known about the frequency of such errors or the processes for managing results that may reduce errors...
  56. ncbi Disruptions in surgical flow and their relationship to surgical errors: an exploratory investigation
    Douglas A Wiegmann
    Department of Surgery, Division of Cardiovascular Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
    Surgery 142:658-65. 2007
    ....
  57. ncbi Medical errors involving trainees: a study of closed malpractice claims from 5 insurers
    Hardeep Singh
    Health Policy and Quality Program, Houston Center for Quality of Care and Utilization Studies, Houston, Texas, USA
    Arch Intern Med 167:2030-6. 2007
    ..the delivery of medical care by trainees involves special risks, information about the types and causes of medical errors involving trainees is limited...
  58. ncbi Patterns of communication breakdowns resulting in injury to surgical patients
    Caprice C Greenberg
    Center for Surgery and Public Health, Brigham and Women s Hospital, Boston, MA 02115, USA
    J Am Coll Surg 204:533-40. 2007
    ..Communication breakdowns are a common threat to surgical safety, but there are little data to guide initiatives to improve communication...
  59. ncbi Wrong-site and wrong-patient procedures in the universal protocol era: analysis of a prospective database of physician self-reported occurrences
    Philip F Stahel
    Department of Orthopaedic Surgery, Denver Health Medical Center, University of Colorado School of Medicine, 80204, USA
    Arch Surg 145:978-84. 2010
    ..To determine the frequency, root cause, and outcome of wrong-site and wrong-patient procedures in the era of the Universal Protocol...
  60. ncbi An unseen danger: frequency of posterior vessel wall penetration by needles during attempts to place internal jugular vein central catheters using ultrasound guidance
    Michael Blaivas
    Northside Hospital Forsyth, Cummings, GA, USA
    Crit Care Med 37:2345-9; quiz 2359. 2009
    ..To evaluate the frequency of unsuspected posterior vessel wall penetration of the internal jugular vein during ultrasound-guided needle cannulation...
  61. ncbi Basics of quality improvement in health care
    Prathibha Varkey
    Divison of Preventive, Occupational and Aerospace Medicine, College of Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
    Mayo Clin Proc 82:735-9. 2007
    ..Key quality improvement concepts and methodologies, including plan-do-study-act, six-sigma, and lean strategies, are discussed, and the differences between quality improvement and quality-of-care research are explored...
  62. pmc Impact of patient communication problems on the risk of preventable adverse events in acute care settings
    Gillian Bartlett
    Department of Family Medicine, McGill University, Montreal, Que
    CMAJ 178:1555-62. 2008
    ..Language barriers and disabilities that affect communication have been shown to decrease quality of care. We sought to assess whether communication problems are associated with an increased risk of preventable adverse events...
  63. pmc Direct medical costs of adverse events in Dutch hospitals
    Lilian H F Hoonhout
    Department of Public and Occupational Health, EMGO Institute, VU University Medical Centre VUmc, Amsterdam, The Netherlands
    BMC Health Serv Res 9:27. 2009
    ..We assessed the total direct medical costs associated with AEs and preventable AEs in Dutch hospitals to gain insight in opportunities for cost savings...
  64. pmc Medical errors related to discontinuity of care from an inpatient to an outpatient setting
    Carlton Moore
    Division of General Internal Medicine, Department of Medicine, Mount Sinai School of Medicine, New York, NY, USA
    J Gen Intern Med 18:646-51. 2003
    To determine the prevalence of medical errors related to the discontinuity of care from an inpatient to an outpatient setting, and to determine if there is an association between these medical errors and adverse outcomes.
  65. pmc Accountability sought by patients following adverse events from medical care: the New Zealand experience
    Marie Bismark
    Health Law, Buddle Findlay, Wellington, NZ
    CMAJ 175:889-94. 2006
    ..This study offers insights into the forms of accountability sought by injured patients and may help to inform tort-reform initiatives...
  66. ncbi The frequency and significance of discrepancies in the surgical count
    Caprice C Greenberg
    Center for Surgery and Public Health, Brigham and Women s Hospital, Boston, Massachusetts 02115, USA
    Ann Surg 248:337-41. 2008
    ..To prospectively evaluate and accurately describe the rate and type of discrepancies encountered in the surgical count...
  67. ncbi Incidence of adverse events related to health care in Spain: results of the Spanish National Study of Adverse Events
    J M Aranaz-Andrés
    Department of Preventive Medicine, Teaching Hospital of Sant Joan d Alacant, Spain
    J Epidemiol Community Health 62:1022-9. 2008
    ..To determine the incidence and incidence density of adverse events (AEs) in Spanish hospitals (including the pre-hospitalisation period)...
  68. ncbi Analysis of surgical errors in closed malpractice claims at 4 liability insurers
    Selwyn O Rogers
    Brigham and Women s Hospital, Boston, Mass Brigham and Women s Hospital and Center for Surgery and Public Health, Boston, Mass, USA
    Surgery 140:25-33. 2006
    ..The relative importance of the different factors that cause surgical error is unknown. Malpractice claim file analysis may help to identify leading causes of surgical error and identify opportunities for prevention...
  69. ncbi A trigger tool to identify adverse events in the intensive care unit
    Roger K Resar
    Luther Midelfort, Mayo Health System, Eau Claire, Wisconsin, USA
    Jt Comm J Qual Patient Saf 32:585-90. 2006
    ..The Trigger Tool technique was used to identify the rate of occurrence of adverse events in the intensive care unit (ICU), and a subset of ICUs described those events in detail...
  70. ncbi Adverse events in the neonatal intensive care unit: development, testing, and findings of an NICU-focused trigger tool to identify harm in North American NICUs
    Paul J Sharek
    Division of General Pediatrics, Department of Pediatrics, Stanford University School of Medicine, 700 Welch Rd, Suite 227, Palo Alto, CA 94304, USA
    Pediatrics 118:1332-40. 2006
    ..The purpose of this work was to develop a NICU-focused tool for adverse event detection and to describe the incidence of adverse events in NICUs identified by this tool...
  71. ncbi Safety climate and medical errors in 62 US emergency departments
    Carlos A Camargo
    Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
    Ann Emerg Med 60:555-563.e20. 2012
    We describe the incidence and types of medical errors in emergency departments (EDs) and assess the validity of a survey instrument that identifies systems factors contributing to errors in EDs.
  72. ncbi The frequency and nature of medical error in primary care: understanding the diversity across studies
    John Sandars
    School of Primary Care, University of Manchester, Walmer Street, Manchester M14 5NP, UK
    Fam Pract 20:231-6. 2003
    ..Understanding the frequency and nature of medical error in primary care is a first step in developing a policy to reduce harm and improve patient safety. There has been scant research into this area...
  73. ncbi Wrong-site craniotomy: analysis of 35 cases and systems for prevention
    Fred L Cohen
    Gary Roberts and Associates, West Palm Beach, Florida, USA
    J Neurosurg 113:461-73. 2010
    ..The clinical consequences of WSC are distinct compared with other types of WSS due to the unique function of the brain...
  74. ncbi Quality indicators in laboratory medicine: a fundamental tool for quality and patient safety
    Mario Plebani
    Department of Laboratory Medicine, University Hospital, Padova, Italy
    Clin Biochem 46:1170-4. 2013
    ..The current lack of attention to extra-laboratory factors is in stark contrast with the body of evidence pointing to the multitude of errors that continue to occur in the pre- and post-analytical phases...
  75. pmc Patient perceptions of mistakes in ambulatory care
    Christine E Kistler
    Division of Geriatrics, Department of Medicin, University of California San Francisco, USA
    Arch Intern Med 170:1480-7. 2010
    ..We aimed to learn about the perceptions of medical mistakes, what factors were associated with perceived mistakes, and whether the participants changed physicians because of these perceived mistakes...
  76. ncbi The detection and prevention of errors in laboratory medicine
    Mario Plebani
    Department of Laboratory Medicine, University Hospital of Padova, Padova, Italy
    Ann Clin Biochem 47:101-10. 2010
    ....
  77. pmc Patient safety education for undergraduate medical students: a systematic review
    Yanli Nie
    Chinese Evidence Based Medicine Centre, West China Hospital Sichuan University, Chengdu 610041, PR China
    BMC Med Educ 11:33. 2011
    ..This paper includes a perspective from the faculty of a medical school, a major hospital and an Evidence Based Medicine Centre in Sichuan Province, China...
  78. ncbi Identification of adverse events at an orthopedics department in Sweden
    Maria Unbeck
    Karolinska Institutet, Department of Clinical Sciences, Danderyd Hospital, Division of Orthopedics, Stockholm, Sweden
    Acta Orthop 79:396-403. 2008
    ..We tested and evaluated a patient safety model (the Wimmera clinical risk management model) and performed a three-stage retrospective review of records to determine the occurrence of AEs in adult orthopedic inpatients...
  79. pmc Adverse events following an emergency department visit
    Alan J Forster
    Ottawa Health Research Institute Clinical Epidemiology Program, Ottawa, Ontario, Canada
    Qual Saf Health Care 16:17-22. 2007
    ..Many studies demonstrate a high rate of treatment-related adverse outcomes or adverse events. No studies have prospectively evaluated adverse events in patients discharged home from the emergency department (ED)...
  80. ncbi Work-arounds in health care settings: Literature review and research agenda
    Jonathon R B Halbesleben
    Department of Management and Marketing, University of Wisconsin Eau Claire, USA
    Health Care Manage Rev 33:2-12. 2008
    ..This suggests a key area of need in the research, particularly because work-arounds are frequently cited in the context of serious patient safety consequences...
  81. pmc Towards an International Classification for Patient Safety: key concepts and terms
    William Runciman
    University of South Australia, Joanna Briggs Institute and Royal Adelaide Hospital, Level 5 McEwin Building, Royal Adelaide Hospital, North Tce Adelaide 5000, SA, Australia
    Int J Qual Health Care 21:18-26. 2009
    ..Understanding the patient safety literature has been compromised by the inconsistent use of language...
  82. ncbi Comparing patient-reported hospital adverse events with medical record review: do patients know something that hospitals do not?
    Joel S Weissman
    Institute for Health Policy, Massachusetts General Hospital, Harvard School of Public Health, Dana Farber Cancer Institute, Boston, Massachusetts, USA
    Ann Intern Med 149:100-8. 2008
    ..Hospitals routinely survey patients about the quality of care they receive, but little is known about whether patient interviews can detect adverse events that medical record reviews do not...
  83. ncbi Minimizing errors of omission: behavioural reenforcement of heparin to avert venous emboli: the BEHAVE study
    J McMullin
    Department of Medicine, McMaster University, Hamilton, ON, Canada
    Crit Care Med 34:694-9. 2006
    ..To improve patient safety by increasing heparin thromboprophylaxis for medical-surgical intensive care unit patients using a multiple-method approach to evidence-based guideline development and implementation...
  84. ncbi Time to listen: a review of methods to solicit patient reports of adverse events
    A King
    Department of Anesthesia, British Columbia Children s Hospital, 4480 Oak Street, Vancouver, British Columbia, Canada
    Qual Saf Health Care 19:148-57. 2010
    Patients have been shown to report accurate observations of medical errors and adverse events...
  85. ncbi Deviations from protocol in a complex trauma environment: errors or innovations?
    Kanav Kahol
    Simulation and Education Training Center, Banner Good Samaritan Medical Center, Phoenix, AZ 85016, USA
    J Biomed Inform 44:425-31. 2011
    ..This research suggests that a novel approach must be taken into consideration for the design of protocols (including standards) and compliance measurements in complex clinical environments...
  86. ncbi Errors and the burden of errors: attitudes, perceptions, and the culture of safety in pediatric cardiac surgical teams
    Agnes Bognar
    Department of Ophthalmology, School of Medicine, University of Szeged, Szeged, Hungary
    Ann Thorac Surg 85:1374-81. 2008
    ..We assessed the perceptions and attitudes of surgical teams relative to committing errors, the impact of errors, and the culture of safety...
  87. ncbi Mapping the limits of safety reporting systems in health care--what lessons can we actually learn?
    Matthew J W Thomas
    School of Psychology, Social Work and Social Policy, University of South Australia, Adelaide, Australia
    Med J Aust 194:635-9. 2011
    ..To assess the utility of Australian health care incident reporting systems and determine the depth of information available within a typical system...
  88. ncbi Discussion of medical errors in morbidity and mortality conferences
    Edgar Pierluissi
    San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
    JAMA 290:2838-42. 2003
    ..Morbidity and mortality conferences in residency programs are intended to discuss adverse events and errors with a goal to improve patient care. Little is known about whether residency training programs are accomplishing this goal...
  89. pmc Extent, nature and consequences of adverse events: results of a retrospective casenote review in a large NHS hospital
    Ali Baba Akbari Sari
    Department of Health Management and Economics, School of Public Health, University of Medical Sciences, Tehran, Iran
    Qual Saf Health Care 16:434-9. 2007
    ..To estimate the extent, nature and consequences of adverse events in a large National Health Service (NHS) hospital, and to evaluate the reliability of a two-stage casenote review method in identifying adverse events...
  90. ncbi Errors in clinical laboratories or errors in laboratory medicine?
    Mario Plebani
    Department of Laboratory Medicine, University Hospital of Padova and Center of Biomedical Research, Castelfranco Veneto, Italy
    Clin Chem Lab Med 44:750-9. 2006
    ..In a modern approach to total quality, centered on patients' needs and satisfaction, the risk of errors and mistakes in pre- and post-examination steps must be minimized to guarantee the total quality of laboratory services...
  91. ncbi Intensive care unit safety incidents for medical versus surgical patients: a prospective multicenter study
    David J Sinopoli
    UMDNJ Robert Wood Johnson Medical School, Piscataway, NJ 08854, USA
    J Crit Care 22:177-83. 2007
    ..The aim of this study is to determine if patient safety incidents and the system-related factors contributing to them systematically differ for medical versus surgical patients in intensive care units...
  92. ncbi Medical errors: impact on clinical laboratories and other critical areas
    Jawahar Kalra
    Department of Pathology, College of Medicine, University of Saskatchewan and Royal University Hospital, Saskatoon, Saskatchewan, Canada
    Clin Biochem 37:1052-62. 2004
    The Institute of Medicine (IOM) report (1999) stated that the prevalence of medical errors is high in today's health care system. Some specialties in health care are more risky than others. A varying blunder/error rate of 0.1-9...
  93. pmc Errors and adverse events in family medicine: developing and validating a Canadian taxonomy of errors
    Sarah Jacobs
    Department of Public Health Sciences, University of Toronto, Ontario
    Can Fam Physician 53:271-6, 270. 2007
    To develop a taxonomy of errors derived solely from the content of error reports using Canadian data from the Primary Care International Study of Medical Errors.
  94. ncbi Adverse events in hospitals: the patient's point of view
    P Massó Guijarro
    Departamento de Psicología de la Salud Universidad Miguel Hernández, Ctra Nacional, N 332, Alicante, Spain
    Qual Saf Health Care 19:144-7. 2010
    ..The aim of this review is to analyse and compare studies about patient's perception and opinion about care safety in hospitals...
  95. ncbi Medical errors: an introduction to concepts
    Jawahar Kalra
    Department of Pathology, College of Medicine, University of Saskatchewan and Royal University Hospital, Saskatoon, Saskatchewan, Canada S7N 0W8
    Clin Biochem 37:1043-51. 2004
    The prevalence of medical errors in health care systems has generated immense interest in recent years. The research on adverse events in hospitalized populations has consistently revealed high rates of adverse events...
  96. ncbi Safety in anaesthesia: a study of 12,606 reported incidents from the UK National Reporting and Learning System
    K Catchpole
    Nuffield Department of Surgery, University of Oxford, Oxford, UK
    Anaesthesia 63:340-6. 2008
    ..Practitioners, departments and professional bodies should consider how the information can be used to promote patient safety and their own defensibility...
  97. ncbi Nursing and patient safety in the operating room
    Herdis Alfredsdottir
    Operating Room, National University Hospital, Reykjavik, Iceland
    J Adv Nurs 61:29-37. 2008
    ..This paper is a report of a study to identify what operating room nurses believe influences patient safety and how they see their role in enhancing patient safety...
  98. ncbi Hospital-reported medical errors in children
    Anthony D Slonim
    Center for Health Services and Clinical Research, Children s Research Institute, Children s National Medical Center, Washington, DC 20010, USA
    Pediatrics 111:617-21. 2003
    b>Medical errors are an important problem for hospitalized adult inpatients. However, medical errors in children remain comparatively understudied, and published research has been relatively limited.
  99. pmc Medical record review of deaths, unexpected intensive care unit admissions, and clinician referrals: detection of adverse events and insight into the system
    K L Dunn
    Department of Paediatrics, University of Melbourne, Australia
    Arch Dis Child 91:169-72. 2006
    ..A quality assurance programme was commenced in 1996...
  100. ncbi Teaching medical students the art of medical error full disclosure: evaluation of a new curriculum
    Anne J Gunderson
    Department of Medical Education, University of Illinois College of Medicine at Chicago, IL 60612, USA
    Teach Learn Med 21:229-32. 2009
    ..Despite the acknowledgment that error disclosure is essential to patient safety and the patient-provider relationship, there is little undergraduate training related to error disclosure...
  101. pmc Major sources of critical incidents in intensive care
    Ingeborg D Welters
    Intensive Care Unit, Royal Liverpool University Hospital, Prescot Street, Liverpool, L7 8XP, UK
    Crit Care 15:R232. 2011
    ....

Research Grants77

  1. Developing, Validating, and Implementing a CKD Predictive Model (DELVECKD)
    KHALED A ABDEL-KADER; Fiscal Year: 2013
    ..prior training in nephrology and a master's in medical education with formal training in adult learning, medical errors, and cognitive theory as well as introductory coursework in clinical research and biostatistics...
  2. FOCUS
    JEFFREY LEE CARSON; Fiscal Year: 2011
    ..Also, this study will measure the frequency and 95% confidence intervals of the medical errors that are important in this patient population and are poorly documented in the literature...
  3. Preventing Nosocomial Respiratory Infections: Patient Safety in the ICU
    Elizabeth Lee Daugherty; Fiscal Year: 2013
    ..by applicant): In 1999, the Institute of Medicine released its report, "To Err is Human," which estimated that medical errors cause 44,000 to 98,000 deaths annually in the U.S...
  4. Silicone-free glass pre-filled syringe system for Biological Drugs.
    VINAY G SAKHRANI; Fiscal Year: 2013
    ..Other advantages of prefilled syringes include reduction in medical errors, ease of use, accurate dosage, elimination of preservatives, and reduction in the amount of drug overfill ..
  5. FOCUS Data Coordinating Center
    Michael L Terrin; Fiscal Year: 2010
    ..90. Also, this study will measure the frequency and 95% confidence intervals of the medical errors that are important in this patient population...
  6. A Multiyear Grant to Support the Diagnostic Error in Medicine (DEM) Annual Confer
    David E Newman-Toker; Fiscal Year: 2012
    DESCRIPTION (provided by applicant): Diagnostic errors account for a significant portion of all medical errors and are responsible for substantial harm and avoidable healthcare costs, yet they have not received the attention that other ..
  7. Multi-Center Trial of Limiting PGY2&3 Resident Work Hours on Patient Safety-CCC
    CHRISTOPHER PAUL LANDRIGAN; Fiscal Year: 2013
    ..first year after medical school (PGY1s) working recurrent shifts over 16 consecutive hours make more serious medical errors than do those working shorter shifts, and suffer more occupational injuries...
  8. Patient-provider communication for patients with communication disorders
    CAROLYN RAE BAYLOR; Fiscal Year: 2013
    ..Because of the communication barriers these patients face, they are at a higher risk for medical errors, poor health outcomes, low satisfaction with healthcare, and exclusion from shared decision-making and higher ..
  9. Healing Without Harm: A Multi-site Demonstration
    Ann Hendrich; Fiscal Year: 2010
    ..model, which will include standardized practices for identifying, responding to, investigating and disclosing medical errors. This is based on the belief that a quick response and early resolution of cases with apparent liability will ..
  10. Emerging Safety and Quality Issues in the Care of Hospitalized Children
    NORA ESTEBAN-CRUVIANI; Fiscal Year: 2013
    ..best practices and healthcare innovations that have proven successful in improving outcomes and reducing medical errors in hospitalized children. Aim 2...
  11. Developing a Medical Biometric Identification System wit a Secure Database Networ
    Jason W Sohn; Fiscal Year: 2012
    ..recognition software to identify patients undergoing radiation therapy or surgical operations to reduce medical errors associated with patient misidentification and failed procedure verification...
  12. Biomarker for Sleep Loss: A Proteomic Determination
    NIRINJINI N NAIDOO; Fiscal Year: 2010
    ..Sleep loss has a major impact on cognitive performance with an increased risk of vehicular crashes, and medical errors. It also results in abnormalities in glucose handling (insulin resistance), increased obesity rates, and is a ..
  13. Bundling Effective Resident Hand Off Practices to Improve Patient Safety
    CHRISTOPHER PAUL LANDRIGAN; Fiscal Year: 2010
    ..Handoff Bundle (RHB) was rapidly adopted by residents and was associated with a 43% reduction in detected medical errors. We now seek to implement the RHB in eight major pediatric residency programs...
  14. A Workshop to Transform Mindsets
    David B Mayer; Fiscal Year: 2010
    ..One such element that is receiving much attention is the full disclosure of medical errors. A hallmark of full disclosure is open and honest communication among patients, families, and providers in the ..
  15. Measuring and Mitigating Patient Safety Threats Due to Strains on ICU Capacity
    SCOTT DAVID HALPERN; Fiscal Year: 2013
    ..and introducing him to ethnographic methods in preparation for future studies of the mechanisms underlying medical errors. Throughout this award, he will be mentored by senior experts in health services research, patient safety, ..
  16. EHR use and care coordination
    Ilana Graetz; Fiscal Year: 2011
    ..Technology, and specifically EHR, offer new opportunities for improving overall quality of care, preventing medical errors, and reducing health care costs...
  17. Improving Patient Safety in a Pediatric Service Line
    TINA SCHADE WILLIS; Fiscal Year: 2011
    ..The majority of adverse events and medical errors are attributed to poor elements of teamwork and unnecessary variation in patient care practices...
  18. A Study of Narrative as the Cognitivie Process Underlying Diagnostic Reasoning
    CURTIS SCOTT SMITH; Fiscal Year: 2010
    ..Research demonstrates that these are the most dangerous types of medical errors. Diagnosis relies on two cognitive processes: one is fast, automatic, and unconscious, while the other is slow,..
  19. Opportunistic Decision Making Information Needs and Workflow in Emergency Care
    Jiajie Zhang; Fiscal Year: 2013
    ..In high risk settings such as the ED, i can lead to suboptimal performance and medical errors. This project targets Area 1 (clinical work) and Area 3 (visualization) in the Program Announcement...
  20. Medical Malpractice and Patient Safety Proposal
    Alice Bonner; Fiscal Year: 2010
    ..Apply evidence from malpractice claims to identify key failure modes contributing to ambulatory medical errors and malpractice suits in order to redesign systems and care processes to prevent, minimize, and mitigate such ..
  21. RFID Application in the Blood Product Supply Chain
    RODEINA RODEINA DAVIS DAVIS; Fiscal Year: 2010
    ..The goal is to create a failsafe system for automatic identification and data capture that will reduce medical errors and enhance the patient safety, quality, and cost-effectiveness of patient-centered transfusion medicine care...
  22. A2ALL- Patient Safety System Improvements in Living Donor Liver Transplantation
    Donna M Woods; Fiscal Year: 2013
    ..transplantation (LDLT), involves complex systems and processes of care that are particularly vulnerable to medical errors and preventable complications...
  23. Effects of Attending Surgeon and Obstetrician Fatigue on Operating Room Safety
    Charles A Czeisler; Fiscal Year: 2012
    ..While nurse and physician-in-training sleep deprivation has been found to significantly increase the risk of medical errors and occupational injuries, very little information has emerged on the relationship between senior (attending) ..
  24. A2ALL- Patient Safety System Improvements in Living Donor Liver Transplantation
    DONNA M contact WOODS; Fiscal Year: 2010
    ..provided by applicant): Significance: The 1999 Institute of Medicine Report (IOM) estimated that preventable medical errors lead to 44,000 - 97,000 deaths in the United States each year (IOM report), greater than the annual number of ..
  25. Software Leveraging a Standards-Based Web Service Framework for Decision Support
    David Lobach; Fiscal Year: 2009
    ..Increased use of decision support tools can be expected to improve care quality, reduce medical errors, lower healthcare costs, and augment disease management for patients and populations.
  26. Transitional Care Medication Safety and Medical Liability: Closing the Chasm
    CINDY LOU CORBETT; Fiscal Year: 2010
    ..In so doing, this grant addresses AHRQ's national effort to combat medical errors and improve patient safety...
  27. Effect of Paramedic Airway Experience on Patient Outcomes
    Henry Wang; Fiscal Year: 2009
    ..In many fields of clinical practice, medical errors are known to be associated with both practitioner procedural volume as well as patient outcome...
  28. SimulTel: Enabling Remote Simultaneous Medical Interpreting
    Jyotsna Changrani; Fiscal Year: 2010
    ..Recently published research has shown that the use of RSMI results in significantly fewer medical errors and is faster than usual and customary interpreting methods. Patient satisfaction is also higher with RSMI...
  29. Medical Liability and Patient Safety Guidelines Project
    LYNN MARIE CRIDER; Fiscal Year: 2010
    ..use state-endorsed evidence-based guidelines and will improve population health by reducing the incidence of medical errors and malpractice claims...
  30. Improving Management of Test Results that Return After Hospital Discharge.
    MARTIN CHIENG WERE; Fiscal Year: 2012
    ..Studies show that nearly half of patients discharged from the hospital with pending test results experience medical errors related to missed tests...
  31. Improving Patient Safety by Reducing Medication Errors
    BRIAN STROM; Fiscal Year: 2005
    ..PROVIDED BY APPLICANT) Medication errors are among the most common and potentially preventable types of medical errors, accounting for more deaths than motor vehicle accidents, breast cancer, or HIV, and an annual cost of $17 to ..
  32. Evaluation of Inpatient Care Teams to Improve Quality
    David H Howard; Fiscal Year: 2013
    Project Summary Medical errors, injuries, and avoidable complications cost billions of dollars annually. Suboptimal teamwork between physicians and nurses in hospitals contributes to higher rates of errors and adverse events...
  33. EHR-based patient safety: Automated error detection in neonatal intensive care
    IMRE SOLTI; Fiscal Year: 2013
    ..3.Study the usefulness of commercial IT systems and EHRs in reducing medical errors. In our study we seek to shift patient safety research toward an automated and computerized approach to ..
  34. When Is Quality Improvement Cost Saving, Cost Effective, or Not a Good Value?
    TERYL NUCKOLS; Fiscal Year: 2013
    ..of medical care are common, including the underuse of necessary care, overuse of inappropriate care, and medical errors. Suboptimal care contributes to avoidable healthcare expenditures, particularly when diseases become ..
  35. TDARS: Translated Document Assembly and Retrieval System (Phase II)
    CYNTHIA ROAT; Fiscal Year: 2011
    ..Health (OMH) identified a national repository of translated documents as a high priority need to reduce medical errors due to language miscommunication...
  36. Immersive Simulation for Design and Evaluation of an Emergency Department IT
    ANN BISANTZ; Fiscal Year: 2013
    ..systems are advocated as solutions to a variety of problems including cost, efficiency, patient safety, and medical errors. However, the critical challenge is in creating information technology solutions that actually deliver the ..
  37. Context-Aware Knowledge Delivery into Electronic Health Records
    Guilherme Del Fiol; Fiscal Year: 2012
    ..percentage of knowledge needs that are raised and not met during the course of care, potentially leading to medical errors and compromising the safety and quality of care...
  38. A New Verification Process to Reduce Dispensing Error Rate in Community Pharmacie
    JENNA LEE; Fiscal Year: 2010
    ..Each year, medical errors cause more than one million injuries and 44,000 deaths in USA alone...
  39. Open Disclosure and Medical Claims Study
    John Buckley; Fiscal Year: 2010
    ..There is a absence of dialogue among physicians, hospitals, and patients regarding patient safety and medical errors due to a fear of malpractice claims and lack of guided communication...
  40. E-Coaching: IVR-Enhanced Care Transition Support for Complex Patients
    Christine S Ritchie; Fiscal Year: 2010
    ..If e-Coach is successful, it is likely to be easily disseminated and could result in substantial avoidance of medical errors in the hospital-to-home transition period along with notable reductions in the risks and costs of re-..
  41. Linking Health Care Workarounds and Burnout to Patient and Worker Safety
    JONATHON RB HALBESLEBEN; Fiscal Year: 2010
    ..is planned, investigating the manner in which nursing workarounds and workforce burnout are associated with medical errors, medical error reporting, and occupational injuries and illnesses of nurses...
  42. Engaging Families in Bedside Rounds to Promote Pediatric Patient Safety
    Elizabeth D Cox; Fiscal Year: 2013
    ..the applicant): Background: Each year, 7 million children are hospitalized in the US, putting them at risk for medical errors. 2 Children suffer three times as many medical errors as adult patients...
  43. Errors and AEs in the setting of neonatal surgery performed in the NICU
    KuoJen Tsao; Fiscal Year: 2013
    ..Surgery and neonatal intensive care units are major contributors to medical errors and adverse events...
  44. Use of Simulation to improve use and safety of Electronic Health Records
    JEFFREY ALLEN GOLD; Fiscal Year: 2013
    ..on EHR safety, that there are many unintended consequences to EHR use, which may in turn actually increase medical errors and in some instances increase patient mortality. This report gave overall EHR safety a grade of C+...
  45. Automated Dynamic Lists for Efficient Electronic Health Record Management
    STEPHANE MICHAEL MEYSTRE; Fiscal Year: 2013
    DESCRIPTION (provided by APPLICANT): Medical errors are recognized as the cause of numerous deaths, and even if some are difficult to avoid, many are preventable...
  46. Communication Processes for Accountable Care Enhancement (C-PACE)
    RUSSELL CHARLES MAULITZ; Fiscal Year: 2013
    ..A successful C-PACE system will improve patient-centered health care, reduce medical errors, and provide the kind of data that CMS, third party payers, Accountable Care Organizations and other health ..
  47. Multimodal Registration of the Brain's Cortical Surface
    MICHAEL IAN MIGA; Fiscal Year: 2012
    ..The other important aspect is the technology we are introducing is relatively inexpensive and is amenable to widespread adoption by medical centers all across the country. ..
  48. Improving Pediatric Resuscitation: A Simulation Program for the Community ED
    Linda L Brown; Fiscal Year: 2013
    ..A portable simulation program, such as this one, could reduce potential medical errors and create a more efficient and safer environment for acutely ill children who seek care in non-children'..
  49. Clinical Decision Support in Community Hospitals: Barriers & Facilitators
    Joan S Ash; Fiscal Year: 2010
    ..indicates that when computerized provider order entry (CPOE) is coupled with clinical decision support (CDS), medical errors may decrease and costs drop...
  50. Improving the Safety and Quality of Pediatric Health Care
    Eric J Thomas; Fiscal Year: 2013
    ..S. and numerous more are injured as a result of medical errors. Research by Dr...
  51. Clinical Study of RFID Tagged Surgical Sponges
    Sharon Morris; Fiscal Year: 2004
    ..The devices described in this application will address some of the most pressing issues in healthcare today: Medical Errors, Nursing Shortage, Skyrocketing Malpractice Premiums and the Efficient Delivery of High Quality Healthcare...
  52. The Value of Hospital-Related Patient-Safety Interventions to Key Stakeholders
    TERYL NUCKOLS; Fiscal Year: 2012
    ..Each year, medical errors harm many hospitalized patients...
  53. HIT for Medication Safety in Critical Access Hospitals
    Abraham Hartzema; Fiscal Year: 2004
    Up to 98,000 deaths occur annually in the United States because of medical errors, with medication errors contributing as many as 7,000 deaths...
  54. RFID Application in the Blood Product Supply Chain
    Rodeina Davis; Fiscal Year: 2007
    ..system for automatic identification and data capture, from collection to transfusion, which will reduce medical errors and enhance the safety, quality and cost-effectiveness of patient-centered care...
  55. Data Flow &Clinical Outcomes in a Perinatal Continuum of Care System
    Donald Levick; Fiscal Year: 2013
    ..at the forefront of the health care improvement agenda because of its potential to achieve the reductions in medical errors and increases in patient safety necessary to improve clinical outcomes and efficiency...
  56. Minimizing Physician Errors: Feedback of Patient Outcomes After Handoffs
    Robert E El-Kareh; Fiscal Year: 2013
    DESCRIPTION (provided by applicant): Medical errors are common, harm patients and increase the cost of healthcare in the US by billions of dollars each year. Many of these errors are preventable...
  57. Internet Utilization for Rural Health Clinics in Indiana
    SHAWNA GIRGIS; Fiscal Year: 2001
    ..clinics and the hospital emergency room to improve / coordinate health care and minimize the potential for medical errors; 5) Develop and test new information technology that will support new health care solutions (e.g...
  58. Status Epilepticus Outcomes in the United States
    Edwin Trevathan; Fiscal Year: 2001
    ..a systematic intervention strategy for SE diagnosis and treatment for these sub-populations that minimizes medical errors, enhances rapid Diagnosis, and improves clinical outcomes; and (c) Study the effectiveness of the new proposed ..
  59. TIPI SYSTEMS TO REDUCE ERRORS IN EMERGENCY CARDIAC CARE
    HARRY SELKER; Fiscal Year: 2002
    ..and occur on a scale that makes them public health issue, and thus present important opportunities to reduce medical errors. This project aims to reduce medical errors in ED triage and treatment for ACI based on a time-insensitive ..
  60. Generating, Evaluating, and Implementing Evidence for Drug-Drug Interactions in H
    Daniel Malone; Fiscal Year: 2009
    ..Most importantly, they are preventable medical errors. A conference that brings together stakeholders to evaluate, discuss, and propose methods to improve the use ..
  61. Patient Safety and the Primary Care Testing Process
    Nancy Elder; Fiscal Year: 2009
    Background: Medical errors in the testing process (ordering, tracking, documentation, patient notification and follow-up) are critical problems in primary care...
  62. The Texas Disclosure and Compensation Study: Best Practices for Improving Safety
    Eric J Thomas; Fiscal Year: 2010
    ..Patients want to know about medical errors, especially errors that directly harm them...
  63. Impact of resident work hour rules on errors and quality
    Kevin Volpp; Fiscal Year: 2007
    ..These rules represent the largest national effort to reduce medical errors since the publication of the Institute of Medicine's To Err is Human in 2000 and will directly impact the ..
  64. SmartTool for Anomaly Detection in Radiotherapy Treatment Plan Data
    TAMARA SIPES; Fiscal Year: 2012
    DESCRIPTION (provided by applicant): Adverse events and medical errors result in thousands of accidental deaths and over one million excess injuries each year...
  65. National EMS Patient Safety Reporting System
    ROLLIN FAIRBANKS; Fiscal Year: 2005
    ..To improve patient safety in EMS a clear understanding of the nature of the medical errors, near misses, and adverse events that occur in EMS must be developed...
  66. Partnering to Improve Patient Safety in Rural WV
    Gail Bellamy; Fiscal Year: 2006
    ..facilities, long term care facilities, and home health agencies, by reducing the occurrences of preventable medical errors, through the use of information healthcare technology...
  67. Rural Iowa Redesign of Care Delivery with EHR Functions
    Donald Crandall; Fiscal Year: 2006
    ..Evaluation measurements will include: a) reported medical errors (including medication errors) and near misses; b) CMS/JCAHO quality measures; c) physician/clinician use of ..
  68. Accountability and Health Safety A Statewide Approach
    Kenneth Thorpe; Fiscal Year: 2004
    ..reporting system was developed to promote a confidential, blame-free environment to facilitate learning from medical errors. The goal of the system is to feedback what is learned to participating hospitals in order to reduce and ..
  69. Virtual Patient Advocate to Reduce Ambulatory Adverse Drug Events
    Brian Jack; Fiscal Year: 2009
    ..The time between hospitalization and the first ambulatory visit is a transition that has a high risk for medical errors. We have developed the "Re-Engineered Hospital Discharge" (RED);ten mutually reinforcing components that are ..
  70. Center for Patient Safety in Neonatal Intensive Care
    Jeffrey Horbar; Fiscal Year: 2003
    We propose to create a Center for Patient Safety in Neonatal Intensive Care to reduce medical errors and e and enhance patient safety for high- risk newborns Our focus will be on "determining to learn most effectively from medical errors ..
  71. Patient safety self-advocacy in patient-centered care
    Nancy Elder; Fiscal Year: 2002
    ..have been studied primarily from the inpatient health care system's perspective; there are minimal data about medical errors in outpatient primary care or how patients actively affect medical errors...
  72. Organizations, Work Environment, and Quality of Care
    Nicholas Warren; Fiscal Year: 2003
    ..ABSTRACT): Health care quality has recently received significant attention, primarily due to the issue of medical errors. We propose an innovative study to a) characterize a multifactoral web of factors that have an impact on ..
  73. Improving safety of pediatric sedation
    JENIFER LIGHTDALE; Fiscal Year: 2006
    ..of sedation involve life-threatening risks to patient safety from unanticipated pharmacological effects or medical errors. Intolerance of IV sedation represents an additional important safety issue, as many children become highly ..
  74. CCHS-East Huron Hospital CPOE Project
    Barbara Moran; Fiscal Year: 2006
    ..care data, improved patient outcomes, standardizes practice variation and use of best practices, reduces medical errors and supports the delivery of a seamless continuum of patient care throughout the Health System...
  75. Mini Bone-Attached Robot for Joint Arthroplasty
    Branislav Jaramaz; Fiscal Year: 2006
    ..This precise placement of the femoral component should reduce the possibility of impingement, patellar maltracking, and component loosening, and improve patient outcomes. ..
  76. Patient Safety for Vulnerable Populations
    Larry Culpepper; Fiscal Year: 2003
    ..as new information has surfaced indicating that each year an alarmingly high number of patients are victims of medical errors that can result in death of severe injury...