To Err Is Human: Building a Safer Health System / Edition 1

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2000-04-15 Hardcover New in Like New jacket Brand new condition hardcover book in its also brand new condition decorative dustjacket. Enjoy being the first to read this book! ... MendoPower Employment Services will immediately and carefully pack this book in high-quality bubble lined, envelopes. Then we send you a confirmation e-mail. We appreciate your business and welcome any questions. Read more Show Less

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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 AIDS -- three causes that receive far more public attention. Indeed, more people die annually from medication errors alone than from workplace injuries. And, although errors may be more easily detected in hospitals, the problems extend to every health care setting, including day-surgery and outpatient clinics, retail pharmacies, nursing homes and home care. And the financial cost to the human tragedy, and medical error easily rises to the top ranks of urgent, widespread health problems.

Faced with these stunning statistics, the Institute of Medicine has initiated a project to examine the issues and recommend rigorous changes in American health care. First in the series of publications from the Quality of Health Care in America project, To Err Is Human breaks the silence that has surrounded medical errors and their consequences -- 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 agenda -- with state and local implications -- for reducing medical errors and improving patient safety through the design of a safer health system.

This volume reveals the often startling truth of medical error and the disparity between the incidence of error and public perception of it. A careful examination is made of how the surrounding forces of legislation, regulation, and market activity influence the quality of care provided and then looks at the handling of medical mistakes.

Using a detailed case study, the book reviews the current understanding of why these mistakes happen. Recognizing that legitimate liability concerns may discourage reporting of errors, the book asks, "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 care -- it is that good people are working in 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 they receive.

This book will be vitally important to federal, state, and local health policymakers and regulators, health professional licensing officials, hospital administrators, medical educators and students, health care-givers, health journalists, patient advocates -- as well as patients themselves.

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Editorial Reviews

Inaugurating the Quality of Health Care in America series, the Institute of Medicine reports on medical errors and their consequences. Rather than pointing fingers at individual health care professionals, they set out a national agenda, with state and local implications, for reducing medical errors and improving patient safety by designing a safer health system. Annotation c. Book News, Inc., Portland, OR (
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Product Details

  • ISBN-13: 9780309068376
  • Publisher: National Academies Press
  • Publication date: 3/1/2000
  • Edition description: New Edition
  • Edition number: 1
  • Pages: 49
  • Product dimensions: 6.38 (w) x 9.36 (h) x 1.06 (d)

Table of Contents

Executive Summary 1
1 A Comprehensive Approach to Improving Patient Safety 17
Patient Safety: A Critical Component of Quality 18
Organization of the Report 21
2 Errors in Health Care: A Leading Cause of Death and Injury 26
Introduction 27
How Frequently Do Errors Occur? 29
Factors That Contribute to Errors 35
The Cost of Errors 40
Public Perceptions of Safety 42
3 Why Do Errors Happen? 49
Why Do Accidents Happen? 51
Are Some Types of Systems More Prone to Accidents? 58
Research on Human Factors 63
Summary 65
4 Building Leadership and Knowledge for Patient Safety 69
Recommendations 69
Why a Center for Patient Safety Is Needed 70
How Other Industries Have Become Safer 71
Options for Establishing a Center for Patient Safety 75
Functions of the Center for Patient Safety 78
Resources Required for a Center for Patient Safety 82
5 Error Reporting Systems 86
Recommendations 87
Review of Existing Reporting Systems in Health Care 90
Discussion of Committee Recommendations 101
6 Protecting Voluntary Reporting Systems From Legal Discovery 109
Recommendation 111
Introduction 112
The Basic Law of Evidence and Discoverability of Error-Related Information 113
Legal Protections Against Discovery of Information About Errors 117
Statutory Protections Specific to Particular Reporting Systems 121
Practical Protections Against the Discovery of Data on Errors 124
Summary 127
7 Setting Performance Standards and Expectations for Patient Safety 132
Recommendations 133
Current Approaches for Setting Standards in Health Care 136
Performance Standards and Expectations for Health Care Organizations 137
Standards for Health Professionals 141
Standards for Drugs and Devices 148
Summary 151
8 Creating Safety Systems in Health Care Organizations 155
Recommendations 156
Introduction 158
Key Safety Design Concepts 162
Principles for the Design of Safety Systems in Health Care Organizations 165
Medication Safety 182
Summary 197
A Background and Methodology 205
B Glossary and Acronyms 210
C Literature Summary 215
D Characteristics of State Adverse Event Reporting Systems 254
E Safety Activities in Health Care Organizations 266
Index 273
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