Medical Errors: Identification and Prevention
State of Florida Mandatory Training

References


Introduction

Defining Medical Errors

What Have We Learned Since the First IOM Report on Medical Errors

Medical Errors in the State of Florida

Intervention: Preventing Medical Errors

Conclusion

Appendix A

Appendix B

References

Test

Exit to Menu

 





Agency for Healthcare Research and Quality (AHRQ). (2006, 2003). Guide to Patient Safety Indicators.

Agency for Healthcare Research and Quality, Rockville, MD. Retrieved September, 2006 at http://www.qualityindicators.ahrq.gov/psi_download.htm.

Agency for Healthcare Research and Quality (AHRQ). (2005). 30 Safe Practices for Better Health Care. Fact Sheet. AHRQ Publication No. 04-P025.

Agency for Healthcare Research and Quality (AHRQ). (2001). Making HealthCare Safer: A Critical Analysis of Patient Safety Practices. AHRQ Publication No. 01-E058. Retrieved May, 2006 at http://www.ahrq.gov/clinic/ptsafety/.

Agency for Healthcare Research and Quality (AHRQ). (2001a) Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Summary. July 2001. AHRQ Publication No. 01-E057. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/clinic/ptsafety/summary.htm.

Agency for Healthcare Research and Quality (AHRQ). (2000). 20 Tips to Help Prevent Medical Errors. Patient Fact Sheet. AHRQ Publication No. 00-PO38, Agency for Healthcare Research and Quality, Rockville, MD. Retrieved May, 2006 at http://www.ahrq.gov/consumer/20tips.htm.

Centers for Disease Control and Prevention (CDC). (2005). Influenza and Influenza Vaccine Information for Healthcare Personnel. Retrieved May, 2006 at http://www.cdc.gov/ncidod/dhqp/id_influenza_vaccine.html.

Centers for Disease Control and Prevention (CDC). (2002). Guideline for hand hygiene in health-care settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Morbidity and Mortality Weekly Report, 51, (RR16), 1-44. Retrieved May, 2006 at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5116a1.htm.

Gallagher, T.H., Garbutt, J. M., Waterman, A.D. (2006). Choosing your words carefully: how physicians would disclose harmful medical errors to patients. Archives of Internal Medicine, 166, 1585-1593.

Gallagher, T. H., Waterman, A. D., Ebers, A. G., Fraser, V. J., & Levinson, W. (2003). Journal of the American Medical Association, 289, 1001-1007.

Gaul, G.M. (July 29, 2005). Plan Would Compile, Analyze Medical Errors; Measure Awaiting Bush's Signature Encourages Confidential Reporting to Improve Health Care. Washington Post, p.A06.

Institute of Medicine (IOM). (2000). Interpreting the Volume-Outcome Relationship in the Context of Health Care Quality: Workshop Summary. Washington, D.C.: National Academies Press.

Institute of Medicine (IOM). (2006). Preventing Medication Errors. National Academies Press: Retrieved July, 2006 at http://www.iom.edu/CMS/3809/22526/35939.aspx.

Institute of Medicine (IOM). (1999). To Err is Human: Building a Better Healthcare System. National Academies Press. Retrieved August, 2006 at http://newton.nap.edu/books/0309068371/html/index.html.

Joint Commission of Accreditation of Healthcare Organizations (JCAHO). (2005). Facts about the Official "Do Not Use" List. Retrieved November, 2005 at http://www.jcaho.org/accredited+organizations/patient+safety/dnu_facts.htm.

Joint Commission of Accreditation of Healthcare Organizations (JCAHO). (2005). Official "Do Not Use" List. Retrieved November, 2005 at http://www.jcaho.org/accredited+organizations/patient+safety/dnu_facts.htm.

Kaiser, K.W. & Steegan, M. B. for the National Quality Forum (NQF). (2002). Serious reportable adverse events in health Care. Advances in Patient Safety, 4, 339-352. Retrieved October, 2006 at http://64.233.167.104/search?q=cache:euS8w0QbmFMJ:www.ahrq.gov/ downloads/pub/advances/vol4/Kizer2.pdf+National+Quality+Forum%27s+serious+reportable +events&hl=en&gl=us&ct=clnk&cd=1

Kizer, K.W. (2003). National Consensus Standards for Safer Healthcare. Power point presentation given on August, 25, 2003. National Patient Safety Foundation. Retrieved August, 2006 at www.ehcca.com/presentations/qualitycolloquium1/kizer.ppt.

Kizer, K. W. (2003). The volume-outcome conundrum. NEJM, 349, 2159-2161.

Mazor, K. M., Reed, G. W., Yood, R. A., Fischer, M.A., Baril, J., Gurwitz, J. H. (2006). Disclosure of medical errors: what factors influence how patients respond? Journal of General Internal Medicine, 21, 7, 704-710.

Mazor, K. M., Simon, S. R., Gurwitz, G.H. (2004). Communicating with patients about medical errors: a review of the literature. Archives of Internal Medicine, 164, 1690-1697.

National Patient Safety Foundation (NPSF). (2005). About the Foundation. Retrieved May, 2006 at http://www.npsf.org/html/about_npsf.html#def.

Quality Interagency Coordination Taskforce (QuIC). (2000). Doing What Counts for Patient Safety: Federal Actions to Reduce Medical Errors and Their Impact. Report of the Quality Interagency Coordination Task Force (QuIC) to the President, February 2000. Retrieved April 2006 at http://www.quic.gov/report/toc.htm.

Shahian, D. M. (2004). Improving cardiac surgery quality-volume, outcome, process? JAMA, 291, 246-248.

Wojcieszak, D., Banja, J., & Houck, C. (2006). The Sorry Works! Coalition: Making the case for full disclosure. Joint Commission Journal on Quality and Patient Safety, 32, 6, 344-350.

Continue on to Test