Understanding medical errors and adverse events in ICU patients

Background: The notion of “just culture” has become a way for hospital administrations to determine employee accountability for medical errors and adverse events. Method: In this paper, we question whether organizational justice can be achieved through algorithmic determination of the intention, volition and repetition of employee actions. Results and conclusion: The analysis in our paper suggests that the construction of evidence and use of power play important roles in the creation of “justice” after iatrogenic harm.

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Do Medical Inpatients Who Report Poor Service Quality Experience More Adverse Events and Medical Errors?

Medical Care ◽

10.1097/mlr.0b013e3181589ba4 ◽

2008 ◽

Vol 46 (2) ◽

pp. 224-228 ◽

Cited By ~ 31

Author(s):

Benjamin B. Taylor ◽

Edward R. Marcantonio ◽

Odelya Pagovich ◽

Alexander Carbo ◽

Margaret Bergmann ◽

...

Keyword(s):

Adverse Events ◽

Service Quality ◽

Medical Errors ◽

Medical Inpatients

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Research Methods, Statistics, Patient Safety, and Quality Improvement

General Pediatrics Board Review ◽

10.1093/med/9780190848712.003.0025 ◽

2020 ◽

pp. 521-530

Author(s):

Carlos Lerner

Keyword(s):

Patient Safety ◽

Quality Improvement ◽

Adverse Events ◽

Research Methods ◽

Confidence Intervals ◽

Medical Errors ◽

Likelihood Ratios ◽

Predictive Values ◽

Analysis Of Variation ◽

Answer Format

The chapter on research methods, statistics, patient safety, and quality improvement (QI) uses a question-and-answer format to make concepts in these areas relevant and accessible to general pediatricians. Research topics covered include study design and study types, validity, sources of bias, types of errors, sensitivity and specificity, positive and negative predictive values, likelihood ratios, incidence and prevalence, p values and confidence intervals. The patient safety questions focus on medical errors and adverse events, including their categorization, detection, prevention, and disclosure. Finally, the QI questions address key QI principles and methods, including tools to understand systems (e.g. fishbone diagrams and Pareto charts), analysis of variation, and the Langley Model for Improvement.

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Recognizing the Ordinary as Extraordinary: Insight Into the “Way We Work” to Improve Patient Safety Outcomes

American Journal of Critical Care ◽

10.4037/ajcc2017812 ◽

2017 ◽

Vol 26 (4) ◽

pp. 272-277 ◽

Cited By ~ 7

Author(s):

Elizabeth A. Henneman

Keyword(s):

Patient Safety ◽

Adverse Events ◽

Eye Tracking ◽

Medical Errors ◽

Improve Patient Safety ◽

Safety Net ◽

Near Miss ◽

The Impact ◽

Risk Processes ◽

Insight Into

The Institute of Medicine (now National Academy of Medicine) reports “To Err is Human” and “Crossing the Chasm” made explicit 3 previously unappreciated realities: (1) Medical errors are common and result in serious, preventable adverse events; (2) The majority of medical errors are the result of system versus human failures; and (3) It would be impossible for any system to prevent all errors. With these realities, the role of the nurse in the “near miss” process and as the final safety net for the patient is of paramount importance. The nurse’s role in patient safety is described from both a systems perspective and a human factors perspective. Critical care nurses use specific strategies to identify, interrupt, and correct medical errors. Strategies to identify errors include knowing the patient, knowing the plan of care, double-checking, and surveillance. Nursing strategies to interrupt errors include offering assistance, clarifying, and verbally interrupting. Nurses correct errors by persevering, being physically present, reviewing/confirming the plan of care, or involving another nurse or physician. Each of these strategies has implications for education, practice, and research. Surveillance is a key nursing strategy for identifying medical errors and reducing adverse events. Eye-tracking technology is a novel approach for evaluating the surveillance process during common, high-risk processes such as blood transfusion and medication administration. Eye tracking has also been used to examine the impact of interruptions to care caused by bedside alarms as well as by other health care personnel. Findings from this safety-related eye-tracking research provide new insight into effective bedside surveillance and interruption management strategies.

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