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Sick Children Crying for Help: Fostering Adverse Event Reports


In a Perspective, Gordon Schiff discusses the importance of appropriately analyzing adverse event reports.


Vyšlo v časopise: Sick Children Crying for Help: Fostering Adverse Event Reports. PLoS Med 14(1): e32767. doi:10.1371/journal.pmed.1002216
Kategorie: Perspective
prolekare.web.journal.doi_sk: https://doi.org/10.1371/journal.pmed.1002216

Souhrn

In a Perspective, Gordon Schiff discusses the importance of appropriately analyzing adverse event reports.


Zdroje

1. Rees P, Edwards A, Powell C, Hibbert P, Williams H, Makeham M, et al. Patient Safety Incidents Involving Sick Children in Primary Care in England and Wales: A Mixed Methods Analysis. PLoS Med. 2017;14(1):e1002217. doi: 10.1371/journal.pmed.1002217

2. Berwick DM, Shojania KG. Free from Harm: Accelerating Patient Safety Improvement Fifteen Years after To Err Is Human. Boston, MA National Patient Safety Foundation; 2015.

3. Vincent C, Amalberti R. Safer Healthcare. Springer; 2016.

4. Macrae C. The problem with incident reporting. BMJ quality & safety. 2016;25(2):71–75.

5. Schiff G, Amato M, Eguale T, et al. Computerised physician order entry-related medication errors: analysis of reported errors and vulnerability testing of current systems. BMJ quality & safety. 2015:bmjqs-2014-003555.

6. Amato MG, Salazar A, Hickman TT, Quist AJ, Volk LA, Wright A, et al. Computerized prescriber order entry–related patient safety reports: analysis of 2522 medication errors. Journal of the American Medical Informatics Association. 2016 Sep 27:ocw125.

7. Schiff G. Using a computerized discharge summary data base check box for adverse drug reaction monitoring. QRB. Quality review bulletin. 1990;16(4):149–155. 2113667

8. Hazell L, Shakir SA. Under-reporting of adverse drug reactions: a systematic review. Drug safety. 2006;29(5):385–396. 16689555

9. Institute for Healthcare Improvement. Ask "Why" Five Times to Get to the Root Cause. http://www.ihi.org/resources/Pages/ImprovementStories/AskWhyFiveTimestoGettotheRootCause.aspx. Accessed December 1, 2016.

10. Benneyan J, Lloyd R, Plsek P. Statistical process control as a tool for research and healthcare improvement. Quality and Safety in Health Care. 2003;12(6):458–464. doi: 10.1136/qhc.12.6.458 14645763

11. Schiff GD. Medical Error: A 60-Year-Old Man With Delayed Care for a Renal Mass. JAMA. 2011;305(18):1890–1898. doi: 10.1001/jama.2011.496 21486963

12. Schiff GD, Puopolo AL, Huben-Kearney A, Yu W, Keohane C, McDonough P et al. Primary Care Closed Claims Experience of Massachusetts Malpractice Insurers. JAMA. 2013;173(22):2063–2068.

13. Shojania KG. The elephant of patient safety: what you see depends on how you look. Joint Commission journal on quality and patient safety / Joint Commission Resources. 2010;36(9):399–401.

14. Marx DA. Patient safety and the" just culture": a primer for health care executives. Trustees of Columbia University; 2001.

15. Sujan MA, Huang H, Braithwaite J. Learning from incidents in health care: Critique from a Safety-II perspective. Safety Science. 2016.

16. Dixon-Woods M, Pronovost PJ. Patient safety and the problem of many hands. BMJ Quality & Safety. 2016;25:485–488.

17. Berwick D. An independent report to the Department of Health. A promise to learn–a commitment to act. Improving the safety of patients in England. 2013. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/226703/Berwick_Report.pdf

Štítky
Interné lekárstvo

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PLOS Medicine


2017 Číslo 1
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