Medical Errors

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  Subject Areas on Research

  • A closer look at associations between hospital leadership walkrounds and patient safety climate and risk reduction: a cross-sectional study. 
  • A controlled laboratory and clinical evaluation of a three-dimensional endoscope for endonasal sinus and skull base surgery. 
  • A necessary sea change for nurse faculty development: spotlight on quality and safety. 
  • A novel technique for VMAT QA with EPID in cine mode on a Varian TrueBeam linac. 
  • A survey-based study of wrong-level lumbar spine surgery: the scope of the problem and current practices in place to help avoid these errors. 
  • Acute decompensation after removing a central line: practical approaches to increasing safety in the intensive care unit. 
  • An XML model that enables the development of complex order sets by clinical experts. 
  • An analysis of the causes of adverse events from the Quality in Australian Health Care Study. 
  • Applying fault tree analysis to the prevention of wrong-site surgery. 
  • Applying the WHO conceptual framework for the International Classification for Patient Safety to a surgical population. 
  • Are physicians' perceptions of healthcare quality and practice satisfaction affected by errors associated with electronic health record use? 
  • Better medicine by default. 
  • Beware of life-threatening activation of air bubble detector during contrast echocardiography in patients on venoarterial extracorporeal membrane oxygenator support. 
  • Burnout in Pediatric Residents: Three Years of National Survey Data. 
  • Can we make postoperative patient handovers safer? A systematic review of the literature. 
  • Checklists, safety, my culture and me. 
  • Clinical Acuity Shorthand System: a standardized classification tool to facilitate handoffs. 
  • Consideration of ICD-9 code-derived disease-specific safety indicators in CKD. 
  • Correction of a saphenous vein graft to coronary vein anastamosis by selective retrograde coil-induced occlusion to arterialize the native vein. 
  • Creating high reliability in health care organizations. 
  • Cultivating a Culture of Medication Safety in Prelicensure Nursing Students. 
  • Defibrillation coil reversal: a rare cause of abnormal noise and inappropriate shocks. 
  • Delayed Admissions to the Pediatric Intensive Care Unit: Progression of Disease or Errors in Emergency Department Management. 
  • Design and implementation of a comprehensive outpatient Results Manager. 
  • Detection of medical errors in kidney transplantation: a pilot study comparing proactive clinician debriefings to a hospital-wide incident reporting system. 
  • Developing and assessing electronic checklists for safety mindfulness, workload, and performance. 
  • Developing process-support tools for patient safety: finding the balance between validity and feasibility. 
  • Development and implementation of a hospital-based patient safety program. 
  • Disclosure and Reflection After an Adverse Event: Tips for Training and Practice. 
  • Disclosure of Medical Errors. 
  • Do opiates affect the clinical evaluation of patients with acute abdominal pain? 
  • Does the use of a prescriptive clinical prediction rule increase the likelihood of applying inappropriate treatments? A survey using clinical vignettes. 
  • Effect of distractions on operative performance and ability to multitask--a case for deliberate practice. 
  • Endovascular aortic balloon clamp malposition during minimally invasive cardiac surgery: detection by transcranial Doppler monitoring. 
  • Endovascular management of inadvertent brachiocephalic arterial catheterization. 
  • Endovascular treatment of inadvertent cannulation of the vertebro-subclavian arterial junction. 
  • Error, stress, and teamwork in medicine and aviation: cross sectional surveys. 
  • Evaluation of the culture of safety: survey of clinicians and managers in an academic medical center. 
  • Examining emergency department communication through a staff-based participatory research method: identifying barriers and solutions to meaningful change. 
  • Exploratory case method to determine the frequency of redundant orders within manually consolidated order lists. 
  • Exploring assumptions about teams. 
  • Failures to discuss and document preferences: Preventable medical errors in stroke care. 
  • Femoral tunnel malposition in ACL revision reconstruction. 
  • Handovers from the OR to the ICU. 
  • Heimlich valve orientation error leading to radiographic tension pneumothorax: analysis of an error and a call for education, device redesign and regulatory action. 
  • How Surgical Trainees Handle Catastrophic Errors: A Qualitative Study. 
  • Impact of patient-specific factors, irradiated left ventricular volume, and treatment set-up errors on the development of myocardial perfusion defects after radiation therapy for left-sided breast cancer. 
  • Implementation of a colour-coded universal protocol safety initiative in Guatemala. 
  • Inadvertent Intrafacet Injection during Lumbar Interlaminar Epidural Steroid Injection: A Comparison of CT Fluoroscopic and Conventional Fluoroscopic Guidance. 
  • Incidence of Inadvertent Intravascular Injection during CT Fluoroscopy-Guided Epidural Steroid Injections. 
  • Incidence of wrong-site surgery among foot and ankle surgeons. 
  • Increased risk for patient safety incidents in hospitalized older adults. 
  • Increasing rate of detection of wrong-patient radiographs: use of photographs obtained at time of radiography. 
  • Interventions to improve transitional care between nursing homes and hospitals: a systematic review. 
  • Interview by Marilyn H. Oermann with Suzanne Delbanco, PhD, executive director of The Leapfrog Group. 
  • Lessons from the past. 
  • Malpositioned left ventricular assist device cannula: diagnosis and management with transesophageal echocardiography guidance. 
  • Malpractice: provider risk or consumer protection? 
  • Managing to improve quality: the relationship between accreditation standards, safety practices, and patient outcomes. 
  • Measurement of quality and assurance of safety in the critically ill. 
  • Measuring safety culture in the ambulatory setting: the safety attitudes questionnaire--ambulatory version. 
  • Medical error. The personal cost. 
  • Medication errors in acute cardiovascular and stroke patients: a scientific statement from the American Heart Association. 
  • Methodologies used in nursing research designed to improve patient safety. 
  • Multicenter automatic defibrillator implantation trial: reduce inappropriate therapy (MADIT-RIT): background, rationale, and clinical protocol. 
  • Narrative feedback from OR personnel about the safety of their surgical practice before and after a surgical safety checklist intervention. 
  • Needs assessment for an errors-based curriculum on thoracoscopic lobectomy. 
  • Neonatal intensive care unit handoffs: a pilot study on core elements and epidemiology of errors. 
  • No difference in postoperative complications, pain, and functional outcomes up to 2 years after incidental durotomy in lumbar spinal fusion: a prospective, multi-institutional, propensity-matched analysis of 1,741 patients. 
  • Nursing patient safety research in rural health care settings. 
  • Operating room briefings and wrong-site surgery. 
  • Operating room debriefings. 
  • Optimizing hospital use of intravenous insulin therapy: improved management of hyperglycemia and error reduction with a new nomogram. 
  • Orthopaedic trauma for the general orthopaedist: avoiding problems and pitfalls in treatment. 
  • Overcoming barriers to adopting and implementing computerized physician order entry systems in U.S. hospitals. 
  • Partnership with patients: a prescription for ICU safety. 
  • Perspectives in quality: designing the WHO Surgical Safety Checklist. 
  • Pigtail Catheter Insertion Error: Root Cause Analysis and Recommendations for Patient Safety. 
  • Precision diagnosis: a view of the clinical decision support systems (CDSS) landscape through the lens of critical care. 
  • Presentation and management of left ventricular assist device inflow cannula malposition. 
  • Pressure waveform monitoring during central venous catheterization. 
  • Prevalence and Predictors of Moral Injury Symptoms in Health Care Professionals. 
  • Prevention of wrong site surgery during upper tract endoscopy. 
  • Quality improvement in pediatrics: past, present, and future. 
  • Reducing health care hazards: lessons from the commercial aviation safety team. 
  • Relationship Between Operating Room Teamwork, Contextual Factors, and Safety Checklist Performance. 
  • Review of Ophthalmology Medical Professional Liability Claims in the United States from 2006 through 2015. 
  • Safety in Hand Surgery: Eliminating Wrong-Site Surgery. 
  • Serendipity or morbidity. 
  • Shame, guilt, and the medical learner: ignored connections and why we should care. 
  • Sometimes determination and compromise thwart success: lessons learned from an effort to study copying and pasting in the electronic medical record. 
  • Statewide Longitudinal Progression of the Whole-Patient Measure of Safety in South Carolina. 
  • Surgical complications. 
  • The Surgical Safety Checklist and Teamwork Coaching Tools: a study of inter-rater reliability. 
  • Thirty-day postoperative death rate at an academic medical center. 
  • To err is human. 
  • To err on humans is not benign. Incentives for adoption of medical error-reporting systems. 
  • Toward learning from patient safety reporting systems. 
  • Translating teamwork behaviours from aviation to healthcare: development of behavioural markers for neonatal resuscitation. 
  • Triggering management for quality improvement. 
  • Two Decades Since To Err Is Human: Progress, but Still a "Chasm". 
  • Two hard lessons. 
  • Understanding situation awareness in nursing work: a hybrid concept analysis 
  • Unintended exposure in radiotherapy: identification of prominent causes. 
  • Use of error management theory to quantify and characterize residents' error recovery strategies. 
  • Using the Web to improve seniors' awareness of their role in preventing medical errors. 
  • Videos in clinical medicine. Central venous catheterization. 
  • When a Surgical Colleague Makes an Error. 
  • Whose fault? 
  • Why we should strive for emotional candour in medical education, too. 
  • World Health Organization Surgical Safety Checklist Modification: Do Changes Emphasize Communication and Teamwork? 
  • [Error, stress and teamwork in medicine and aviation. A cross-sectional study]. 
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  Keywords of People

  • Barbeito, Atilio, Associate Professor of Anesthesiology, Anesthesiology
  • Bynum IV, William Edwards, Associate Professor in Family Medicine and Community Health, Family Medicine and Community Health, Family Medicine
  • Milano, Carmelo Alessio, Joseph W. and Dorothy W. Beard Distinguished Professor of Experimental Surgery, Surgery, Cardiovascular and Thoracic Surgery
  • Taekman, Jeffrey Marc, Professor Emeritus of Anesthesiology, Anesthesiology, Neuroanesthesia