College of American Pathologists Special Topic Symposium on Error in Pathology and Laboratory Medicine—Practical Lessons for the Pathologist: Introduction

2005 ◽  
Vol 129 (10) ◽  
pp. 1226-1227
Author(s):  
Richard J. Zarbo ◽  
Ronald L. Sirota
Keyword(s):  
Health Care ◽  
Patient Safety ◽  
Quality Management ◽  
Medical Error ◽  
Laboratory Medicine ◽  
Error Reduction ◽  
Error Reporting ◽  
Special Topic ◽  
Risk Avoidance ◽  
National Patient

Abstract This article is an overview to the all-day special topic symposium on patient safety and error reduction, entitled “Error in Pathology and Laboratory Medicine: Practical Lessons for the Pathologist,” which was held at the College of American Pathologists annual meeting in Scottsdale, Ariz, on September 20, 2004. The intent of the symposium was to provide pathologists with useful take-home lessons related to error identification, reduction, and risk avoidance for adoption in practice. Error reduction in the laboratory has always been an implied, if not directly stated goal of laboratory quality management programs, but given the nature of humans to err, the call for redesign of the health care system, and the impending threat of national patient safety legislation calling for medical error reporting and disclosure, we believe that this topic of error will be one of continued interest to practicing pathologists for many years.

Medical Error as False Claim

2001 ◽  
Vol 27 (2-3) ◽  
pp. 181-201
Author(s):  
Joan H. Krause
Keyword(s):  
Health Care ◽  
Medical Errors ◽  
Medical Error ◽  
Error Reduction ◽  
Error Reporting ◽  
Academic Press ◽  
Institute Of Medicine ◽  
Health Care Fraud ◽  
False Claim ◽  
The U.S

[I]n appropriate instances, the U.S. Attorney's Office will act to investigate and pursue systemic substandard care issues, notwithstanding a provider's representation of compliance with administrative requirements.Medical error and health care fraud are hot topics these days. Since the Fall 1999 publication of the Institute of Medicine (“IOM”) Report,To Err is Human,medical errors have received a great deal of attention in the popular and academic press. Error reporting bills have been introduced at both the state and federal levels, and industry and government representatives have undertaken a variety of cooperative error-reduction efforts.

Medical Error Reporting, Patient Safety, and the Physician

2009 ◽  
Vol 5 (3) ◽  
pp. 176-179 ◽  
Author(s):  
Britta Anderson ◽  
Paul G. Stumpf ◽  
Jay Schulkin
Keyword(s):  
Patient Safety ◽  
Medical Error ◽  
Error Reporting

Patient Safety and Error Reduction

2013 ◽  
Author(s):  
Graham Brack ◽  
Penny Franklin ◽  
Jill Caldwell
Keyword(s):  
Patient Safety ◽  
Health Authority ◽  
Healthcare Professionals ◽  
Care Patient ◽  
Error Reduction ◽  
National Patient Safety Agency ◽  
Do No Harm ◽  
National Patient ◽  
Compensation Claims ◽  
Special Health

Most healthcare professionals take up their career because they want to make people better. It is rare—but not unknown—to find nurses deliberately harming patients. It is not always possible to cure a patient’s condition, and readers may be surprised to hear the view of Lord Justice Stuart-Smith that our ‘only duty as a matter of law is not to make the victim’s condition worse’ (Capital and Counties plc v Hampshire CC (1997) 2 All ER 865 at 883). Despite our best intentions, healthcare professionals do sometimes make the patient’s condition worse. There are too many instances of harm caused to patients. Not only does the patient suffer harm, staff will be upset (some may even give up their careers) and large compensation claims may be made which deplete NHS resources. According to the NHS Litigation Authority, in 2010–11 it received 8655 claims of clinical negligence and 4346 claims of non-clinical negligence against NHS bodies, and paid £863 million in connection with clinical negligence claims (NHSLA Annual Report and Accounts, 2011). To put that into perspective, NHS Warwickshire had a budget of £827m for that year, so this amount would fund a mediumsized PCT. For all these reasons, therefore, our first concern must be to do no harm to our patient. If we can improve their condition, so much the better, but at the very least we must leave them no worse off for having put themselves in our care. Patient safety must be everyone’s concern. It is monitored by the NHS Commissioning Board Special Health Authority. Until June 2012 there was a separate agency, the National Patient Safety Agency (NPSA), which produced a report in 2009 entitled Safety in doses: improving the use of medicines in the NHS . There were 811 746 reports to the NPSA in 2007, of which 86 085 were related to medication. The figures for July 2010– June 2011 show an increase to 1.27 million incidents, of which 133 727 were related to medication.

scholarly journals Patient Safety, Risk Reduction, and the Law

2018 ◽  
Author(s):  
Larry I. Palmer
Keyword(s):  
Health Care ◽  
Patient Safety ◽  
Health System ◽  
Systems Thinking ◽  
Health Care System ◽  
Error Reduction ◽  
Medical Liability ◽  
Starting Point ◽  
Care System

36 Houston Law Review 1609 (1999)"Patient safety" has come of age. With the publication of several empirical studies of medical injuries and the recent Institute of Medicine Report, To Err is Human: Building a Safe Health System, scholars from a variety of disciplines are advocating "systems thinking" as a way of preventing medical accidents. These scholars have been influenced by efforts to reduce accidents in other high risk industries such as aviation and scholarship in law proposing "no fault systems" for compensating medical accident victims. This article proposes that in order to incorporate "systems thinking" about medical error reduction, legal scholarship on the health care system must move beyond its preoccupation with the medical liability system. To develop a new framework for the role of law in enhancing patient safety, this article proposes that law's interaction with the public health system is the appropriate starting point for framing the legal analysis of patient safety. This framing of the issues acknowledges that the liability system may have a role to play in error reduction in medicine, but determining what this role is requires more empirical study of legal institutions as part of the emerging system of patient safety. To discover the appropriate role of law in the prevention of medical errors, this article encourages legal scholars to learn to pose empirical questions about how various institutions interact with the health care system.

Application of Quality Management in Promoting Patient Safety and Preventing Medical Errors

2017 ◽  
pp. 91-112
Author(s):  
Ali Mohammad Mosadeghrad ◽  
Abraha Woldemichael
Keyword(s):  
Health Care ◽  
Patient Safety ◽  
Quality Management ◽  
Medical Errors ◽  
Health Professionals ◽  
Quality Health Care ◽  
Near Misses ◽  
Management Framework ◽  
Quality Health ◽  
Health Institutions

The combination of healthcare professionals, processes and technologies bring significant benefits for patients. However, it also involves an inevitable risk of adverse events. Patients receiving health care in health institutions have the potential to experience some forms of medical errors. The word medical error commonly encompasses terms such as mistakes, near misses, active and latent errors. This signifies the complexity and multidimensional nature of the error. The consequences can be costly to the patients, the health professionals, the health care institutions, and the entire health care system. The costs may involve human, economic, and social aspects. Thus, ensuring quality health care can contribute to patients' safety by reducing potential medical errors in practice. This chapter aims to introduce a quality management framework for improving the quality and effectiveness of services, reducing medical errors and making the healthcare system safer for patients.

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