Medical Errors and Patient Safety (eBook)

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Jay Kalra, College of Medicine, University of Saskatchewan, Canada.

Contents 8
Acknowledgments 10
About the author 12
Abbreviations 14
1 An overview and introduction to concepts 16
1.1 Introduction 16
1.2 Medical error 17
1.3 Magnitude and epidemiology of health care errors 19
1.4 Conclusion 23
2 Perceptions of medical error and adverse events 26
2.1 Introduction 26
2.2 Perceptions by physicians 27
2.3 Perceptions by the public 28
2.4 Perceptions by health care staff 30
2.5 Perceptions by medical students 32
2.6 A sociological perception of medical error 34
2.7 Conclusion 35
3 Causes of medical error and adverse events 38
3.1 Introduction 38
3.2 The cognitive influence on error-generating behavior 42
3.3 Conclusion 43
4 Medical error and strategies for working solutions in clinical diagnostic laboratories and other health care areas 46
4.1 Introduction 46
4.2 Clinical diagnostic laboratories 47
4.3 Errors in different stages of analysis 49
4.4 Strategies for identification and prevention of errors 51
4.5 Errors in emergency medicine 53
4.6 Errors in intensive care medicine 56
4.7 Conclusion 60
5 Creating a culture for medical error reduction 66
5.1 Introduction 66
5.2 Education and professional development 67
5.3 Error reporting systems 72
5.4 Leadership and regulatory issues 74
5.5 Establishing a quality care council 75
5.6 Emotional impact of errors on health care professionals 76
5.7 Conclusion 76
6 Improving quality in clinical diagnostic laboratories 80
6.1 Introduction 80
6.2 Efforts and programs to ensure quality in clinical diagnostic laboratories 81
6.3 Proficiency testing in clinical laboratories 84
6.4 External quality assessment and proficiency testing programs 85
6.5 "No-fault" model 87
6.6 Conclusion 88
7 Barriers to open disclosure 92
7.1 Introduction 92
7.2 How to disclose 92
7.3 Disclosing errors to multiple patients 93
7.4 Bioethical viewpoints 94
7.5 Patient-physician relations 95
7.6 The dilemma of an apology 96
7.7 Barriers to full disclosure 98
7.8 Conclusion 99
8 International laws and guidelines addressing error and disclosure 102
8.1 Introduction 102
8.2 Disclosing preventable adverse events 102
8.3 International progress and initiatives 103
8.4 Conclusion 107
9 The value of autopsy in detecting medical error and improving quality 110
9.1 Introduction 110
9.2 Error in diagnostic medicine 110
9.3 Missed diagnosis and discordance 111
9.4 The value of autopsies 112
9.5 Autopsy decline and strategies to encourage autopsy 113
9.6 Conclusion 114
10 Total quality management, six-sigma, and health care 118
10.1 Introduction 118
10.2 New issues, newer solutions 119
10.3 The six-sigma structure 121
10.4 Six-sigma in clinical diagnostic laboratories 123
10.5 Conclusion 124
Index 126

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"Ein komprimierter Überblick über modernes Fehlermanagement."
In: Chirurgenmagazin 4/2011