Abstract
In their work as health care professionals, both authors have gained vital experience in error management. They draw our attention to the human tendency to focus only on a single reason when dealing with errors. To mitigate this tendency, they show a two-step alternative process. The first step, a “sequence of events analysis,” is conducted immediately after an accident or near miss. This data capture serves to inform the later, second analysis, called a “focused event analysis.” The focused event analysis is a causal analysis study involving all key stakeholders for the purpose of seeking knowledge about the contributing variables and the steps that can be taken to eliminate system vulnerabilities.
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References
Agency for Healthcare Research and Quality. 2016. Hospital survey on patient safety culture. http://www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/hospital/index.html
———. n.d. About the PSO program: A brief history of the program. https://pso.ahrq.gov/about
Ayanian, J.Z. 2003. Is geography destiny? Illuminating the survival advantage of elderly patients in New England after acute myocardial infarction. American Heart Journal 146 (2): 207–209. https://doi.org/10.1016/s0002-8703(03)00238-2.
Bari, A., R.A. Khan, and A.W. Rathore. 2016. Medical errors; causes, consequences, emotional response and resulting behavioral change. Pakistan Journal of Medical Sciences 32 (3): 523–528. https://doi.org/10.12669/pjms.323.9701.
Bell, S.K., A.A. White, J.C. Yi, J.P. Yi-Frazier, and T.H. Gallagher. 2015. Transparency when things go wrong: Physician attitudes about reporting medical errors to patients, peers, and institutions. Journal of Patient Safety. https://doi.org/10.1097/pts.0000000000000153.
Bosk, C. 1979. Forgive and remember: Managing medical failure. Chicago: University of Chicago Press.
Chantler, C. 1999. The role and education of doctors in the delivery of health care. Lancet 353 (9159): 1178–1181. https://doi.org/10.1016/s0140-6736(99)01075-2.
Dolgin, N.H., B. Movahedi, P.N. Martins, R. Goldberg, K.L. Lapane, F.A. Anderson, and A. Bozorgzadeh. 2016. Decade-long trends in liver transplant waitlist removal due to illness severity: The impact of centers for medicare and medicaid services policy. Journal of the American College of Surgeons 222 (6): 1054–1065. https://doi.org/10.1016/j.jamcollsurg.2016.03.021.
Donaldson, L. 2002. An organisation with a memory. Clinical Medicine (London) 2 (5): 452–457.
Dornfeld, S. 2000. Preventing medical errors. Sint Paul Pioneer Press, July 17, p. 8A.
Editorial Board. 2009. A national survey of medical error reporting laws. Yale Journal of Health Policy, Law, and Ethics 9 (1): 201–286.
Editorial Department. 2000. Children’s hospitals: Worthy effort to improve health care. Star Tribune, p. A12.
Edmondson, A. 2011. Strategies for learning from failure. Harvard Business Review 89 (4): 48–55, 137.
Edmondson, A., M. Roberto, and A. Tucker. 2001. Children’s hospital and clinics. Harvard Business Review. https://doi.org/PRODUCT#: 302050-PDF-ENG
Fabreau, G.E., A.A. Leung, D.A. Southern, M.L. Knudtson, J.M. McWilliams, J.Z. Ayanian, and W.A. Ghali. 2014. Sex, socioeconomic status, access to cardiac catheterization, and outcomes for acute coronary syndromes in the context of universal healthcare coverage. Circulation Cardiovascular Quality and Outcomes 7 (4): 540–549. https://doi.org/10.1161/circoutcomes.114.001021.
Fang, J., and M.H. Alderman. 2003. Is geography destiny for patients in New York with myocardial infarction? American Journal of Medicine 115 (6): 448–453.
Fein, S.P., et al. 2007. The many faces of error disclosure: A common set of elements and a definition. Journal of General Internal Medicine 22 (6): 755–761. https://doi.org/10.1007/s11606-007-0157-9.
Gallagher, T.H.S., and W. Levinson. 2007. Disclosing harmful medical errors to patients. New England Journal of Medicine 356 (26): 2713–2719.
Ghalandarpoorattar, S.M., A. Kaviani, and F. Asghari. 2012. Medical error disclosure: The gap between attitude and practice. Postgrad Medical Journal 88 (1037): 130–133. https://doi.org/10.1136/postgradmedj-2011-130118.
Hickson, G.B., E.W. Clayton, P.B. Githens, and F.A. Sloan. 1992. Factors that prompted families to file medical malpractice claims following perinatal injuries. JAMA 267 (10): 1359–1363.
Hingorani, M., T. Wong, and G. Vafidis. 1999. Patients’ and doctors’ attitudes to amount of information given after unintended injury during treatment: Cross sectional, questionnaire survey. BMJ 318 (7184): 640–641.
Howard Mason, P. 2009. The power of place: Geography, destiny, and globalization’s rough landscape, by Harm de Blij. Anthropology & Medicine 16 (3): 333–336. https://doi.org/10.1080/13648470903295992.
Kachalia, A., and D.W. Bates. 2014. Disclosing medical errors: The view from the USA. The Surgeon 12 (2): 64–67. https://doi.org/10.1016/j.surge.2013.12.002.
Kohn, L.T., J. Corrigan, and M.S. Donaldson. 2000. To err is human: Building a safer health system. Washington, DC: The National Academies Press. https://doi.org/10.17226/9728.
Leape, L., et al. 2009. Transforming healthcare: A safety imperative. Quality and Safety in Health Care 18 (6): 424–428. https://doi.org/10.1136/qshc.2009.036954.
Lewey, J., and N.K. Choudhry. 2014. The current state of ethnic and racial disparities in cardiovascular care: Lessons from the past and opportunities for the future. Current Cardiology Reports 16 (10): 530. https://doi.org/10.1007/s11886-014-0530-3.
Libungan, B. 2015. Acute coronary syndrome and cardiac arrest in the elderly. Doctor of Philosophy (Medicine), University of Gothenburg. Sahlgrenska Academy, Gothenburg, Sweden. https://gupea.ub.gu.se/handle/2077/38347(978–91–628-9294-4)
Lucian Leape Institute. 2015. Shining a light: Safer health care through transparency. A roundtable on transparency. Boston: National Patient Safety Foundation. http://www.npsf.org/?shiningalight
Makary, M.A., and M. Daniel. 2016. Medical error-the third leading cause of death in the US. BMJ 353: i2139. https://doi.org/10.1136/bmj.i2139.
Mankiw, N.G. 2007. Principles of microeconomics. 4th ed. Mason: Thomson Higher Education.
Manser, T., and S. Staender. 2005. Aftermath of an adverse event: Supporting health care professionals to meet patient expectations through open disclosure. Acta Anaesthesiologica Scandinavica 49 (6): 728–734. https://doi.org/10.1111/j.1399-6576.2005.00746.x.
Martinez, W., and L.S. Lehmann. 2013. The “hidden curriculum” and residents’ attitudes about medical error disclosure: Comparison of surgical and nonsurgical residents. Journal of the American College of Surgeons 217 (6): 1145–1150. https://doi.org/10.1016/j.jamcollsurg.2013.07.391.
Martinez, W., et al. 2014. Role-modeling and medical error disclosure: A national survey of trainees. Academic Medicine 89 (3): 482–489. https://doi.org/10.1097/acm.0000000000000156.
Mazor, K.M., et al. 2013. More than words: Patients’ views on apology and disclosure when things go wrong in cancer care. Patient Education and Counseling 90 (3): 341–346. https://doi.org/10.1016/j.pec.2011.07.010.
McKinney, M. 2012. For better or worse. Report: Where you live affects the type of healthcare you’re going to get. Modern Healthcare 42 (12): 6–7.
McLennan, S.R., M. Diebold, L.E. Rich, and B.S. Elger. 2016. Nurses’ perspectives regarding the disclosure of errors to patients: A qualitative study. International Journal of Nursing Studies 54: 16–22. https://doi.org/10.1016/j.ijnurstu.2014.10.001.
Morath, J.M., and J.E. Turnbull. 2005. To do no harm: Ensuring patient safety in health care organizations. San Francisco: Jossey-Bass.
National Patient Safety Foundation. 2009. The universal patient compact. http://c.ymcdn.com/sites/www.npsf.org/resource/resmgr/PDF/UniversalPatientCompact.pdf
Nunn, A., A. Yolken, B. Cutler, S. Trooskin, P. Wilson, S. Little, and K. Mayer. 2014. Geography should not be destiny: Focusing HIV/AIDS implementation research and programs on microepidemics in US neighborhoods. American Journal of Public Health 104 (5): 775–780. https://doi.org/10.2105/ajph.2013.301864.
O’Toole, J., and W. Bennis. 2009. What’s needed next: A culture of candor. Harvard Business Review 87 (6): 54–61.
Office for National Statistics’ Death Certification Advisory Group. 2010. Guidance for doctors completing medical certificates of cause of death in England and Wales. http://www.gro.gov.uk/images/medcert_July_2010.pdf.
Periyakoil, V.S. 2008. Geography decides destiny. Journal of Palliative Medicine 11 (5): 694–695. https://doi.org/10.1089/jpm.2008.9905.
Plews-Ogan, M., N. May, J. Owens, M. Ardelt, J. Shapiro, and S.K. Bell. 2016. Wisdom in medicine: What helps physicians after a medical error? Academic Medicine 91 (2): 233–241. https://doi.org/10.1097/acm.0000000000000886.
Powell, S.K. 2006. When things go wrong: Responding to adverse events: A consensus statement of the Harvard hospitals. Lippincotts Case Management 11 (4): 193–194.
Pronovost, P.J., et al. 2006. A web-based tool for the Comprehensive Unit-based Safety Program (CUSP). Joint Commission Journal on Quality and Patient Safety 32 (3): 119–129.
Prouty, C.D., M.B. Foglia, and T.H. Gallagher. 2013. Patients’ experiences with disclosure of a large-scale adverse event. Journal of Clinical Ethics 24 (4): 353–363.
Rosenthal, J. 2007. Advancing patient safety through state reporting systems. Perspectives on safety. https://psnet.ahrq.gov/perspectives/perspective/43/advancing-patient-safety-through-state-reporting-systems
Schwappach, D.L. 2015. In the aftermath of medical error: Caring for patients, family, and the healthcare workers involved. Bundesgesundheitsblatt, Gesundheitsforschung, Gesundheitsschutz 58 (1): 80–86. https://doi.org/10.1007/s00103-014-2083-4.
Shapiro, J. 2000. Taking the mistakes out of medicine. US News and World Report 129: 50–54.
Snyder, L. 2012. American college of physicians ethics manual. Sixth edition. Annals of Internal Medicine 156 (1 Pt 2): 73–104. https://doi.org/10.7326/0003-4819-156-1-201201031-00001.
Statistics Canada. n.d. Canadian vital statistics, death database and population estimates. http://www.statcan.gc.ca/tables-tableaux/sum-som/l01/cst01/hlth36a-eng.htm
Stroud, L., B.M. Wong, E. Hollenberg, and W. Levinson. 2013. Teaching medical error disclosure to physicians-in-training: A scoping review. Academic Medicine 88 (6): 884–892. https://doi.org/10.1097/ACM.0b013e31828f898f.
The Joint Commission. 2015. Comprehensive accreditation manual. CAMH for hospitals: The official handbook. http://www.jcrinc.com/2016-comprehensive-accreditation-manual-for-hospitals-camh-/
Timmel, J., P.S. Kent, C.G. Holzmueller, L. Paine, R.D. Schulick, and P.J. Pronovost. 2010. Impact of the comprehensive unit-based safety program (CUSP) on safety culture in a surgical inpatient unit. Joint Commission Journal on Quality and Patient Safety 36 (6): 252–260.
Tsao, K., and M. Browne. 2015. Culture of safety: A foundation for patient care. Seminars in Pediatric Surgery 24 (6): 283–287. https://doi.org/10.1053/j.sempedsurg.2015.08.005.
Ubel, P.A. 2014. Transplantation traffic – Geography as destiny for transplant candidates. New England Journal of Medicine 371 (26): 2450–2452. https://doi.org/10.1056/NEJMp1407639.
Virginia Mason Institute. 2014. Terrible tragedy – And powerful legacy – of preventable death. https://www.virginiamasoninstitute.org/2014/03/terrible-tragedy-and-powerful-legacy-of-preventable-death/
Wahid, N.N., S.H. Moppett, and I.K. Moppett. 2016. Quality of quality accounts: Transparency of public reporting of never events in England. A semi-quantitative and qualitative review. Journal of the Royal Society of Medicine 109 (5): 190–199. https://doi.org/10.1177/0141076816636367.
White, A.A., and T.H. Gallagher. 2013. Medical error and disclosure. Handbook of Clinical Neurology 118: 107–117. https://doi.org/10.1016/b978-0-444-53501-6.00008-1.
Yusuf, S., et al. 2011. Use of secondary prevention drugs for cardiovascular disease in the community in high-income, middle-income, and low-income countries (the PURE Study): A prospective epidemiological survey. Lancet 378 (9798): 1231–1243. https://doi.org/10.1016/s0140-6736(11)61215-4.
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Morath, J., Johnson, M. (2018). Open Error Communication in a High-Consequence Industry. In: Hagen, J. (eds) How Could This Happen?. Palgrave Macmillan, Cham. https://doi.org/10.1007/978-3-319-76403-0_10
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