"The 1999 Institute of Medicine (IOM) report, 'To Err is Human,' shocked people and catalyzed a new focus on patient safety. As our understanding of patient safety and error reduction has matured, we recognized the untapped power and drama of the individual case presentation," said Robert Wachter, MD, associate chairman of the UCSF department of medicine and executive editor of the new series. "By presenting and analyzing individual cases, we can educate physicians to understand the role of both individual and systems factors that merge to create a medical error."
In the first article, "The Wrong Patient," two patient safety experts from The Mount Sinai School of Medicine in New York describe the 17 errors that allowed one patient to receive an invasive procedure intended for another patient at an unidentified institution. This, along with all other cases, is based on real experiences and includes analyses from the top experts in the field. However, cases do not originate from the experts' home institutions, nor do they identify hospitals or physicians, according to the editors.
"The incident reviewed in the first article raises disturbing questions about the adequacy of patient safety systems in hospitals," said Mark Chassin, MD, chairman of health policy at Mount Sinai School of Medicine and lead author of "The Wrong Patient." Chassin formerly served as New York State Health Commissioner.
"In the complex environment of the modern hospital, preventable injuries to patients are most often caused by a combination of breakdowns in communication and teamwork and faulty information systems. Industries such as aerospa
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Contact: Maureen McInaney
mmcinaney@pubaff.ucsf.edu
415-476-2557
University of California - San Francisco
3-Jun-2002