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REFERENCES

  • 1
    Kohn LT, Corrigan JM, Donaldson MS, eds. To Err is Human. Washington DC: National Academy Press, 1999.
  • 2
    Expert Group on Learning from Adverse Events in the NHS. An Organisation With a Memory. London: Stationery Office; 2000.
  • 3
    Bates DW, Gawande AA. Error in medicine: what have we learned. Ann Intern Med. 2000;132: 7637.
  • 4
    Weingart SN, Wilson RM, Gibberd RW, Harrison B. Epidemiology of medical error. BMJ. 2000;320: 7747.
  • 5
    Brennan TA. The Institute of Medicine report on medical errors—could it do harm? N Engl J Med. 2000;342: 11235.
  • 6
    Mc Donald CJ, Weiner M, Hui SL. Deaths due to medical errors are exaggerated in Institute of Medicine report. JAMA. 2000;284: 935.DOI: 10.1001/jama.284.1.93
  • 7
    Sox HC, Woloshin S. How many deaths are due to medical error? Getting the number right. Eff Clin Pract. 2000;3: 27783.
  • 8
    Hofer TP, Kerr EA. What is an error? Eff Clin Pract. 2000;3: 2619.
  • 9
    Wears RL, Janiak B, Moorehead JC, et al. Human error in medicine: promise and pitfalls, part 2. Ann Emerg Med. 2000;36: 1424.DOI: 10.1067/mem.2000.108713
  • 10
    Leape LL, Berwick DM, Bates DW. What practices will most improve patient safety? Evidence-based medicine meets patient safety. JAMA. 2002;288: 5017.DOI: 10.1001/jama.288.4.501
  • 11
    Shojania KG, Duncan BW, Mc Donald KM, Wachter RM. Safe but sound. Patient safety meets evidence-based medicine. JAMA. 2002;288: 50813.DOI: 10.1001/jama.288.4.508
  • 12
    Reason J. Human Error. Cambridge: Cambridge University Press; 1990.
  • 13
    Hulley SB, Martin JN, Cummings SR. Planning the measurements: precision and accuracy. In: Designing Clinical Research: An Epidemiologic Approach. HulleySB, CummingsSR, eds. Philadelphia: Lippincott; 2001: 37.
  • 14
    Leape LL, Bates DW, Cullen DJ. Systems analysis of adverse drug events. ADE prevention study. JAMA. 1995;274: 3543.DOI: 10.1001/jama.274.1.35
  • 15
    Perrow C. Normal Accidents: Living With High Risk Technologies. New York: Basic Books; 1984.
  • 16
    Gordon L. Gordon's Guide to the Surgical Morbidity and Mortality Conference. Philadelphia: Hanley and Belfus; 1994.
  • 17
    Accreditation Council for Graduate Medical Education. Essentials and Information Items. Graduate Medical Education Directory. Chicago Ill: American Medical Association; 1995.
  • 18
    Harbison S, Regehr G. Faculty and resident opinions regarding the role of Morbidity and Mortality Conference. Am J Surg 1999;177: 1369.DOI: 10.1016/S0002-9610(98)00319-5
  • 19
    Goldman L, Sayson R, Robbins S, Cohn LH, Bettmann M, Weisberg M. The value of the autopsy in three medical eras. N Engl J Med. 1983;308: 10005.
  • 20
    Cameron HM, Mc Googan E. A prospective study of 1152 hospital autopsies, I: inaccuracies in death certification. J Pathol. 1981;133: 27383.
  • 21
    Anderson RE, Hill RB, Key CR. The sensitivity and specificity of clinical diagnostics during five decades: toward an understanding of necessary fallibility. JAMA. 1989;261: 161017.DOI: 10.1001/jama.261.11.1610
  • 22
    Sackett DL, Haynes RB, Guyatt GH, Tugwell P. Clinical Epidemiology. Boston: Little Brown, and Company; 1991.
  • 23
    Fischoff B. Hindsight does not equal foresight: the effect of outcome knowledge on judgment under uncertainty. J Exp Psychol Hum Percept Perform. 1975;1: 28899.DOI: 10.1037//0096-1523.1.3.288
  • 24
    Caplan RA, Posner KL, Cheney FW. Effect of outcome on physician judgments of appropriateness of care. JAMA. 1991;265: 195760.
  • 25
    Cheney FW, Posner K, Caplan RA, Ward RJ. Standard of care and anesthesia liability. JAMA. 1989;261: 15991603.
  • 26
    Rolph JE, Kravitz RL, McGuigan K. Malpractice claims data as a quality improvement tool. II. Is targeting effective? JAMA. 1991;266: 20937.DOI: 10.1001/jama.266.15.2093
  • 27
    Weiler PC. Medical Malpractice on Trial. Cambridge, Mass: Harvard University Press; 1991.
  • 28
    Eichhorn JH, Cooper JB, Cullen DJ, Maier WR, Philip JH, Seeman RG. Standards for patient monitoring during anesthesia at Harvard Medical School. JAMA. 1986;256: 101720.DOI: 10.1001/jama.256.8.1017
  • 29
    Barach P, Small SD. Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems. BMJ. 2000;320: 75963.
  • 30
    Sexton JB, Thomas EJ, Helmreich RL. Error, stress, and teamwork in medicine and aviation: cross-sectional surveys. BMJ. 2000;320: 7459.
  • 31
    Brennan TA, Lee TH, O'Neil AC, Petersen LA. Integrating providers into quality improvement: a pilot project at one hospital. Qual Manag Health Care. 1992;1: 2935.
  • 32
    Edmonson AC. Learning from mistakes is easier said than done: group and organizational influences on the detection and correction of human error. J Appl Behav Sci. 1996;32: 528.
  • 33
    O'Neil AC, Petersen LA, Cook EF, Bates DW, Lee TH, Brennan TA. A comparison of physicians self-reporting to medical record review to identify medical adverse events. Ann Intern Med. 1993;119: 3706.
  • 34
    Petersen LA, Brennan TA, O'Neil AC, Cook EF, Lee TH. Does house staff discontinuity of care increase the risk for preventable adverse events? Ann Intern Med. 1994;121: 86672.
  • 35
    Petersen LA, Orav EJ, Teich JM, O'Neil AC, Brennan TA. Using a computerized sign-out to improve continuity of inpatient care and prevent adverse events. Jt Comm J Qual Improv. 1998;24: 7787.
  • 36
    Iezzoni LI. Assessing quality using administrative data. Ann Intern Med. 1997;127: 66674.
  • 37
    Iezzoni LI. Identifying complications of care using administrative data. Med Care. 1994;32: 70015.
  • 38
    Iezzoni LI, Davis RB, Palmer RH, et al. Does the Complications Screening Program flag cases with process of care problems? Using explicit criteria to judge processes. Int J Qual Health Care. 1999;11: 10718.DOI: 10.1093/intqhc/11.2.107
  • 39
    Weingart SN, Iezzoni LI, Davis RB, et al. Use of administrative data to find substandard care: validation of the complications screening program. Med Care. 2000;38: 796806.DOI: 10.1097/00005650-200008000-00004
  • 40
    Bates DW, O'Neil AC, Petersen LA, Lee TH, Brennan TA. Evaluation of screening criteria for adverse events in medical patients. Med Care. 1995;33: 45262.
  • 41
    Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence care in hospitalized patients. N Engl J Med. 1991;324: 3706.
  • 42
    Ashton CM, Kuykendall DH, Johnson ML, Wray NP. An empirical assessment of the validity of explicit and implicit process of care criteria for quality assessment. Med Care. 1999;37: 798808.DOI: 10.1097/00005650-199908000-00009
  • 43
    Localio AR, Lawthers A, Brennan TA. Identifying adverse events caused by medical care: degree of physician agreement in retrospective chart review. Ann Intern Med. 1996;125: 45764.
  • 44
    Luck J, Peabody JW, Dresselhaus TR, Lee M, Glassman P. How well does chart abstraction measure quality? A prospective comparison of standardized patients with the medical record. Am J Med. 2000;108: 6429.DOI: 10.1016/S0002-9343(00)00363-6
  • 45
    Classen DC, Pestotnik SL, Evans RS, Burke JP. Computerized surveillance of adverse drug events in hospital patients. JAMA. 1991;266: 284751.
  • 46
    Jha AK, Kuperman GJ, Teich JM, et al. Identifying adverse drug events: development of a computer-based monitor and comparison to chart-review and stimulated voluntary report. J Am Med Inform Assoc. 1998;5: 30514.
  • 47
    Helmreich RL, Schaefer HG. Team performance in the operating room. In: BognerMS, ed. Human Error in Medicine. Hillsdale NJ: Lawrence Erlbaum Associates; 1994: 22553.
  • 48
    Donchin Y, Gopher D, Olin M, et al. A look into the nature and causes of human errors in the intensive care unit. Crit Care Med. 1995;23: 294300.DOI: 10.1097/00003246-199502000-00015
  • 49
    Andrews LB, Stocking C, Krizek T, et al. An alternative strategy for studying adverse events in medical care. Lancet. 1997;349: 30913.DOI: 10.1016/S0140-6736(96)08268-2
  • 50
    Barker KN. Data collection techniques: observation. Am J Hosp Pharm. 1980;37: 123543.
  • 51
    Cook RI, Woods DD. Operating at the sharp end: the complexity of human error. In: BognerMS, ed. Human Error in Medicine. Hillsdale NJ: Lawrence Erlbaum Associates; 1994.
  • 52
    Last JM. A Dictionary of Epidemiology. New York: Oxford University Press; 1995.
  • 53
    Mangano DT, Goldman L. Preoperative assessment of patients with known or suspected coronary disease. N Engl J Med. 1995;333: 17506.DOI: 10.1056/NEJM199512283332607
  • 54
    Lee TH, Marcantonio ER, Mangione CM, et al. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation. 1999;100: 10439.
  • 55
    Gaynes RP, Horan TC. Surveillance of nosocomial infections. In: MayhallGC, ed, Hospital Epidemiology and Infection Control. Philidelphia: Lippincott Williams and Wilkins; 1999.