To Err Is Human

To Err Is Human
Author: Institute of Medicine,Committee on Quality of Health Care in America
Publsiher: National Academies Press
Total Pages: 312
Release: 2000-03-01
Genre: Medical
ISBN: 9780309068376

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Experts estimate that as many as 98,000 people die in any given year from medical errors that occur in hospitals. That's more than die from motor vehicle accidents, breast cancer, or AIDSâ€"three causes that receive far more public attention. Indeed, more people die annually from medication errors than from workplace injuries. Add the financial cost to the human tragedy, and medical error easily rises to the top ranks of urgent, widespread public problems. To Err Is Human breaks the silence that has surrounded medical errors and their consequenceâ€"but not by pointing fingers at caring health care professionals who make honest mistakes. After all, to err is human. Instead, this book sets forth a national agendaâ€"with state and local implicationsâ€"for reducing medical errors and improving patient safety through the design of a safer health system. This volume reveals the often startling statistics of medical error and the disparity between the incidence of error and public perception of it, given many patients' expectations that the medical profession always performs perfectly. A careful examination is made of how the surrounding forces of legislation, regulation, and market activity influence the quality of care provided by health care organizations and then looks at their handling of medical mistakes. Using a detailed case study, the book reviews the current understanding of why these mistakes happen. A key theme is that legitimate liability concerns discourage reporting of errorsâ€"which begs the question, "How can we learn from our mistakes?" Balancing regulatory versus market-based initiatives and public versus private efforts, the Institute of Medicine presents wide-ranging recommendations for improving patient safety, in the areas of leadership, improved data collection and analysis, and development of effective systems at the level of direct patient care. To Err Is Human asserts that the problem is not bad people in health careâ€"it is that good people are working in bad systems that need to be made safer. Comprehensive and straightforward, this book offers a clear prescription for raising the level of patient safety in American health care. It also explains how patients themselves can influence the quality of care that they receive once they check into the hospital. This book will be vitally important to federal, state, and local health policy makers and regulators, health professional licensing officials, hospital administrators, medical educators and students, health caregivers, health journalists, patient advocatesâ€"as well as patients themselves. First in a series of publications from the Quality of Health Care in America, a project initiated by the Institute of Medicine

The Poet s Mistake

The Poet s Mistake
Author: Erica McAlpine
Publsiher: Princeton University Press
Total Pages: 296
Release: 2020-06-09
Genre: Literary Criticism
ISBN: 9780691203768

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What our tendency to justify the mistakes in poems reveals about our faith in poetry—and about how we read Keats mixed up Cortez and Balboa. Heaney misremembered the name of one of Wordsworth's lakes. Poetry—even by the greats—is rife with mistakes. In The Poet's Mistake, critic and poet Erica McAlpine gathers together for the first time numerous instances of these errors, from well-known historical gaffes to never-before-noticed grammatical incongruities, misspellings, and solecisms. But unlike the many critics and other readers who consider such errors felicitous or essential to the work itself, she makes a compelling case for calling a mistake a mistake, arguing that denying the possibility of error does a disservice to poets and their poems. Tracing the temptation to justify poets' errors from Aristotle through Freud, McAlpine demonstrates that the study of poetry's mistakes is also a study of critical attitudes toward mistakes, which are usually too generous—and often at the expense of the poet's intentions. Through remarkable close readings of Wordsworth, Keats, Browning, Clare, Dickinson, Crane, Bishop, Heaney, Ashbery, and others, The Poet's Mistake shows that errors are an inevitable part of poetry's making and that our responses to them reveal a great deal about our faith in poetry—and about how we read.

Bozo Sapiens

Bozo Sapiens
Author: Michael Kaplan,Ellen Kaplan
Publsiher: Bloomsbury Publishing USA
Total Pages: 302
Release: 2009-08-01
Genre: Science
ISBN: 9781608192120

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The New York Times called Chances Are, the authors' look at the application of probability in everyday life, a "dizzying, exhilarating ride." In Bozo Sapiens, they take us on a another funhouse journey, exploring the surprising, or alarming, number of ways that humans can make bad judgments and poor decisions. The Kaplans' ability to explain everything from statistics to evolutionary biology in witty, accessible, and anecdotal style will endear this book to readers of Blink, Freakonomics, and other recent pop-social science successes.

Improving Diagnosis in Health Care

Improving Diagnosis in Health Care
Author: National Academies of Sciences, Engineering, and Medicine,Institute of Medicine,Board on Health Care Services,Committee on Diagnostic Error in Health Care
Publsiher: National Academies Press
Total Pages: 473
Release: 2015-12-29
Genre: Medical
ISBN: 9780309377720

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Getting the right diagnosis is a key aspect of health care - it provides an explanation of a patient's health problem and informs subsequent health care decisions. The diagnostic process is a complex, collaborative activity that involves clinical reasoning and information gathering to determine a patient's health problem. According to Improving Diagnosis in Health Care, diagnostic errors-inaccurate or delayed diagnoses-persist throughout all settings of care and continue to harm an unacceptable number of patients. It is likely that most people will experience at least one diagnostic error in their lifetime, sometimes with devastating consequences. Diagnostic errors may cause harm to patients by preventing or delaying appropriate treatment, providing unnecessary or harmful treatment, or resulting in psychological or financial repercussions. The committee concluded that improving the diagnostic process is not only possible, but also represents a moral, professional, and public health imperative. Improving Diagnosis in Health Care, a continuation of the landmark Institute of Medicine reports To Err Is Human (2000) and Crossing the Quality Chasm (2001), finds that diagnosis-and, in particular, the occurrence of diagnostic errorsâ€"has been largely unappreciated in efforts to improve the quality and safety of health care. Without a dedicated focus on improving diagnosis, diagnostic errors will likely worsen as the delivery of health care and the diagnostic process continue to increase in complexity. Just as the diagnostic process is a collaborative activity, improving diagnosis will require collaboration and a widespread commitment to change among health care professionals, health care organizations, patients and their families, researchers, and policy makers. The recommendations of Improving Diagnosis in Health Care contribute to the growing momentum for change in this crucial area of health care quality and safety.

Health IT and Patient Safety

Health IT and Patient Safety
Author: Institute of Medicine,Board on Health Care Services,Committee on Patient Safety and Health Information Technology
Publsiher: National Academies Press
Total Pages: 234
Release: 2012-04-15
Genre: Computers
ISBN: 9780309221122

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IOM's 1999 landmark study To Err is Human estimated that between 44,000 and 98,000 lives are lost every year due to medical errors. This call to action has led to a number of efforts to reduce errors and provide safe and effective health care. Information technology (IT) has been identified as a way to enhance the safety and effectiveness of care. In an effort to catalyze its implementation, the U.S. government has invested billions of dollars toward the development and meaningful use of effective health IT. Designed and properly applied, health IT can be a positive transformative force for delivering safe health care, particularly with computerized prescribing and medication safety. However, if it is designed and applied inappropriately, health IT can add an additional layer of complexity to the already complex delivery of health care. Poorly designed IT can introduce risks that may lead to unsafe conditions, serious injury, or even death. Poor human-computer interactions could result in wrong dosing decisions and wrong diagnoses. Safe implementation of health IT is a complex, dynamic process that requires a shared responsibility between vendors and health care organizations. Health IT and Patient Safety makes recommendations for developing a framework for patient safety and health IT. This book focuses on finding ways to mitigate the risks of health IT-assisted care and identifies areas of concern so that the nation is in a better position to realize the potential benefits of health IT. Health IT and Patient Safety is both comprehensive and specific in terms of recommended options and opportunities for public and private interventions that may improve the safety of care that incorporates the use of health IT. This book will be of interest to the health IT industry, the federal government, healthcare providers and other users of health IT, and patient advocacy groups.

Crossing the Quality Chasm

Crossing the Quality Chasm
Author: Institute of Medicine,Committee on Quality of Health Care in America
Publsiher: National Academies Press
Total Pages: 360
Release: 2001-08-19
Genre: Medical
ISBN: 9780309072809

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Second in a series of publications from the Institute of Medicine's Quality of Health Care in America project Today's health care providers have more research findings and more technology available to them than ever before. Yet recent reports have raised serious doubts about the quality of health care in America. Crossing the Quality Chasm makes an urgent call for fundamental change to close the quality gap. This book recommends a sweeping redesign of the American health care system and provides overarching principles for specific direction for policymakers, health care leaders, clinicians, regulators, purchasers, and others. In this comprehensive volume the committee offers: A set of performance expectations for the 21st century health care system. A set of 10 new rules to guide patient-clinician relationships. A suggested organizing framework to better align the incentives inherent in payment and accountability with improvements in quality. Key steps to promote evidence-based practice and strengthen clinical information systems. Analyzing health care organizations as complex systems, Crossing the Quality Chasm also documents the causes of the quality gap, identifies current practices that impede quality care, and explores how systems approaches can be used to implement change.

Blue Threat

Blue Threat
Author: Tony Kern
Publsiher: Unknown
Total Pages: 256
Release: 2009-09
Genre: Attention
ISBN: 0984206302

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Making Healthcare Safe

Making Healthcare Safe
Author: Lucian L. Leape
Publsiher: Springer Nature
Total Pages: 450
Release: 2021-05-28
Genre: Medical
ISBN: 9783030711238

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This unique and engaging open access title provides a compelling and ground-breaking account of the patient safety movement in the United States, told from the perspective of one of its most prominent leaders, and arguably the movement’s founder, Lucian L. Leape, MD. Covering the growth of the field from the late 1980s to 2015, Dr. Leape details the developments, actors, organizations, research, and policy-making activities that marked the evolution and major advances of patient safety in this time span. In addition, and perhaps most importantly, this book not only comprehensively details how and why human and systems errors too often occur in the process of providing health care, it also promotes an in-depth understanding of the principles and practices of patient safety, including how they were influenced by today’s modern safety sciences and systems theory and design. Indeed, the book emphasizes how the growing awareness of systems-design thinking and the self-education and commitment to improving patient safety, by not only Dr. Leape but a wide range of other clinicians and health executives from both the private and public sectors, all converged to drive forward the patient safety movement in the US. Making Healthcare Safe is divided into four parts: I. In the Beginning describes the research and theory that defined patient safety and the early initiatives to enhance it. II. Institutional Responses tells the stories of the efforts of the major organizations that began to apply the new concepts and make patient safety a reality. Most of these stories have not been previously told, so this account becomes their histories as well. III. Getting to Work provides in-depth analyses of four key issues that cut across disciplinary lines impacting patient safety which required special attention. IV. Creating a Culture of Safety looks to the future, marshalling the best thinking about what it will take to achieve the safe care we all deserve. Captivatingly written with an “insider’s” tone and a major contribution to the clinical literature, this title will be of immense value to health care professionals, to students in a range of academic disciplines, to medical trainees, to health administrators, to policymakers and even to lay readers with an interest in patient safety and in the critical quest to create safe care.