To Err Is Human Building a Safer Health System

ISBN-10: 0309068371

ISBN-13: 9780309068376

Edition: 2000

List price: $39.95
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Book details

List price: $39.95
Copyright year: 2000
Publisher: National Academies Press
Publication date: 3/1/2000
Binding: Hardcover
Pages: 312
Size: 10.00" wide x 6.50" long x 1.00" tall
Weight: 1.782
Language: English

Executive Summary
A Comprehensive Approach to Improving Patient Safety
Patient Safety: A Critical Component of Quality
Organization of the Report
Errors in Health Care: A Leading Cause of Death and Injury
Introduction
How Frequently Do Errors Occur?
Factors That Contribute to Errors
The Cost of Errors
Public Perceptions of Safety
Why Do Errors Happen?
Why Do Accidents Happen?
Are Some Types of Systems More Prone to Accidents?
Research on Human Factors
Summary
Building Leadership and Knowledge for Patient Safety
Recommendations
Why a Center for Patient Safety Is Needed
How Other Industries Have Become Safer
Options for Establishing a Center for Patient Safety
Functions of the Center for Patient Safety
Resources Required for a Center for Patient Safety
Error Reporting Systems
Recommendations
Review of Existing Reporting Systems in Health Care
Discussion of Committee Recommendations
Protecting Voluntary Reporting Systems From Legal Discovery
Recommendation
Introduction
The Basic Law of Evidence and Discoverability of Error-Related Information
Legal Protections Against Discovery of Information About Errors
Statutory Protections Specific to Particular Reporting Systems
Practical Protections Against the Discovery of Data on Errors
Summary
Setting Performance Standards and Expectations for Patient Safety
Recommendations
Current Approaches for Setting Standards in Health Care
Performance Standards and Expectations for Health Care Organizations
Standards for Health Professionals
Standards for Drugs and Devices
Summary
Creating Safety Systems in Health Care Organizations
Recommendations
Introduction
Key Safety Design Concepts
Principles for the Design of Safety Systems in Health Care Organizations
Medication Safety
Summary
Appendixes
Background and Methodology
Glossary and Acronyms
Literature Summary
Characteristics of State Adverse Event Reporting Systems
Safety Activities in Health Care Organizations
Index
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