Patient Safety and Acute Care Medicine: Lessons for the Future, Insights from the Past

  • P. G. Brindley
Conference paper


It is estimated that approximately 40,000–100,000 Americans die annually from medical errors [2]. Thousands more suffer harm from medical errors. Still others are exposed to errors, but are lucky enough to suffer no obvious harm [3]. In fact, medical errors are now the eighth leading cause of death in the USA; data are no less alarming from other nations [4]. Regardless of the exact figures, it seems that patient safety is far from adequate. Crudely put, if medicine were a patient, we physicians would say it is time to admit there is a problem. We would expect urgent action, and we would welcome any ideas, rather than tolerate further delays. This chapter hopes to provide a call-to-arms, but most importantly a range of ideas, both new and old, to achieve the sort of care that our patients deserve.


Patient Safety Medical Error Situational Awareness Crisis Management Medical Simulation 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


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  1. 1.
    Arthur Schopenhauer quotes (2009) Available at: Accessed Dec 2009Google Scholar
  2. 2.
    Kohn LT, Corrigan J, Donaldson MS (2000) To Err is Human: Building a Safer Health System. National Academy Press, WashingtonGoogle Scholar
  3. 3.
    Aron D, Headrick L (2002) Educating physicians prepared to improve care and safety is no accident: it requires a systematic approach. Qual Saf Health Care 11: 168–173CrossRefPubMedGoogle Scholar
  4. 4.
    Baker G.R, Norton PG, Flintoft V, et al (2004). The Canadian Adverse Events study: the incidence of adverse events among hospital patients in Canada. Can Med Assoc J 170: 1678–1686CrossRefGoogle Scholar
  5. 5.
    Albert Einstein quotes. Available at: Accessed Dec 2009Google Scholar
  6. 6.
    St Pierre M, Hofinger G, Buerschaper C (2008) Basic principles: error, complexity and human behavior. In: St Pierre M, Hofinger G, Buerschaper C (eds) Crisis Management in Acute Care Settings: Human factors and team psychology in a high stakes environment. Springer, New York, pp 1–16Google Scholar
  7. 7.
    Dunn W, Murphy JG (2008). Simulation: About safety, not fantasy. Chest 133: 6–9CrossRefPubMedGoogle Scholar
  8. 8.
    Engineering-Wikipedia, the free encyclopedia (2009) Available at: wikilengineering. Accessed Dec 2009Google Scholar
  9. 9.
    New York Times (October 18 2007). Fatal Airline crashes drop 65 0/0. Available at: http:// I/businesslO 1safety.html. Accessed Dec 2009Google Scholar
  10. 10.
    Barry R, Murcko A, Brubaker C (2002) The Six Sigma Book for Healthcare: Improving Outcomes by Reducing Errors. Health Administration Press, ChicagoGoogle Scholar
  11. 11.
    “Failing to plan is planning to fail”. Available at: plan_is_plannin~to/175849.html. Accessed Dec 2009Google Scholar
  12. 12.
    Gaba DM, Fish KJ, Howard SK (1994) Crisis Management in Anesthesiology. Churchill Livingstone, New YorkGoogle Scholar
  13. 13.
    RaIl M, Gaba D (2005) Human performance and patient safety. In: Miller R (ed) Miller’s Anesthesia. Elsevier Churchill Livingstone, Philadelphia, pp 3021–3072Google Scholar
  14. 14.
    Leonard M, Graham S, Bonacum D (2004) The Human Factor: The critical importance of effective teamwork and communication in providing safe care. Qual Saf Health Care 13: 185–190CrossRefGoogle Scholar
  15. 15.
    Koontz NA, Gunderman RB (2008) Gestalt theory: implications for radiology education. Am J Roentgenol. 190: 1156–1160CrossRefGoogle Scholar
  16. 16.
    Gestalt psychology. Available at: Accessed Dec 2009Google Scholar
  17. 17.
    Berner ES, Graber, ML (2008) Overconfidence as a Cause of Diagnostic Error in Medicine. Am J Med 121 (5 Suppl): S2–23CrossRefPubMedGoogle Scholar
  18. 18.
    Occam’s Razor. Wikipedia, the free encyclopedia Available at: Occam’s_razor. Accessed Dec 2009Google Scholar
  19. 19.
    Schwab AP (2008) Putting cognitive psychology to work: Improving decision-making in the medical encounter. Soc Sci Med 67: 1861–1869CrossRefPubMedGoogle Scholar
  20. 20.
    Elstein AS (1999) Heuristics and biases: selected errors in clinical reasoning. Acad Med 74: 791–794CrossRefPubMedGoogle Scholar
  21. 21.
    Miah A (2008) A Deep Blue grasshopper. Playing games with artificial intelligence. In: Benjamin Hale (ed) Philosophy Looks at Chess. Open Court, Chicago, pp 13–24Google Scholar
  22. 22.
    Hartmann J (2008). Garry Kasparov is a cyborg, or What ChessBase teaches us about technology. In: Benjamin Hale (ed) Philosophy Looks at Chess. Open Court, Chicago, pp 39–64Google Scholar
  23. 23.
    Rosen KR (2008) The history of medical simulation. J Crit Care 23: 157–166CrossRefPubMedGoogle Scholar
  24. 24.
    Proctor RN (2008) Agnotology: A missing term to describe the cultural production of ignorance (and its study). In: Proctor R.N, Schiebinger L (eds) Agnotology: The Making and Unmaking of Ignorance. Stanford University Press, Stanford, pp 1–36Google Scholar
  25. 25.
    Gaba DM (1992) Improving anesthesiologists' performance by simulating reality. Anesthesiology 76: 491–494CrossRefPubMedGoogle Scholar

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© Springer Science + Business Media Inc. 2010

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  • P. G. Brindley

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