Grant 1
Patient Disclosure
Legal and Policy Approaches 114
Incentives 17
Malpractice Litigation 53
Delirium 1
Charles Vincent, PhD; October 2003
Trusting his memory more than the chart, a surgeon directs a resident to remove the wrong side on a patient with unilateral vulvar cancer.
Misread Label
Bryony Dean Franklin, PhD; November 2003
An infant born with sluggish breathing is given Lanoxin instead of naloxone, and dies of digoxin toxicity.
Mark My Tooth
Richard A. Smith, DDS; July-August 2007
A patient underwent tooth extraction, but awoke from anesthesia and found that the wrong two teeth had been removed.
How Do Providers Recover From Errors?
Colin P. West, MD, PhD; January 2008
An elderly man with COPD and end-stage congestive heart failure was admitted for increasing shortness of breath, due to a pleural effusion. A resident performed a thoracentesis on the wrong side, and the patient developed a pneumothorax and died. The resident disclosed the error but was devastated.
Tough Call: Addressing Errors From Previous Providers
William Martinez, MD, MS, and Gerald B. Hickson, MD; March 2014
Hospitalized 3 times within 2 months presumably for sepsis, a woman with diabetes on metformin presented to the emergency department with the same set of symptoms as her previous admissions. After reviewing her records, the admitting team determined that the patient's presentation for this and earlier admissions was more consistent with acute lactic acidosis secondary to metformin than sepsis.
In Conversation with...Allan Frankel, MD
Patient Safety Programs, July 2006
Allan Frankel, MD, is Director of Patient Safety for Partners HealthCare, the merged entity of Harvard hospitals and clinics that includes Massachusetts General and Brigham and Women's Hospital. Dr. Frankel, an anesthesiologist by training, has been a key member of the faculty of the Institute for Healthcare Improvement, co-chairing numerous Adverse Drug Events and Patient Safety Collaboratives. Dr. Frankel's work in patient safety focuses on leadership training, high reliability in health care, teamwork development, and cultural change. We asked Dr. Frankel to speak with us about developing a comprehensive patient safety program.
In Conversation with...Lucian Leape, MD
Reflections on the History of the Patient Safety Movement, August 2006
Lucian Leape, MD, is generally known as the father of the modern patient safety movement in the United States. A Harvard professor, Leape shifted his career two decades ago from his clinical practice as a pediatric surgeon to a focus on understanding how medical errors occur and how patient safety can be improved. The result was several groundbreaking studies and commentaries that helped shift the paradigm from "bad people" to "bad systems," and which paved the way for the Institute of Medicine report, "To Err is Human," which he helped write. He has received dozens of honors, including the John M. Eisenberg patient safety award, the duPont Award for Excellence in Children's Health Care, and the Robert Wood Johnson Foundation Investigator's Award in Health Policy Research. He spoke to us about his remarkable career and his thoughts about the patient safety movement.