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Автор: Grafiati
Опубліковано: 4 червня 2021
Оновлено: 25 січня 2023

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1

Ebrahimi, Sedigheh, Seyed Ziaedin Tabei, Fatemeh Kalantari, and Alireza Ebrahimi. "Medical Interns’ Perceptions about Disclosing Medical Errors." Education Research International 2021 (August 25, 2021): 1–10. http://dx.doi.org/10.1155/2021/1102135.

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Background. Honest and timely reporting of medical errors is the professional and ethical duty of any physician as it can help the patients and their families to understand the condition and enable the practitioners to prevent the consequences of the error. This study aims to investigate the viewpoints of medical interns regarding medical error disclosure in educational hospitals in Shiraz, Iran. Methods. A researcher-made questionnaire was used for data collection. The survey consisted of questions about the medical error disclosure, the willingness to disclose an error, the interns’ experiences and intentions of reporting the medical error, and two scenarios to assess the students’ response to a medical error. Results. Medical interns believed that a medical error must be reported for the sake of conscience and commitment and prevention of further consequences. The most important cause of not reporting an error was found to be inappropriate communication skills among the students. The results indicated that the willingness to disclose the hypothetical error among females was more than males (R < 0.005), but in practice, there was no difference between males and females (R > 0.005). The willingness to disclose minor and major hypothetical errors had a positive correlation ( P < 0.001 , R = 0.848). Conclusion. More ethical training and education of communication skills would be helpful to persuade physicians to disclose medical errors.
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2

Piryani, R. M. "Medical error." Journal of Chitwan Medical College 4, no. 4 (January 28, 2015): 1. http://dx.doi.org/10.3126/jcmc.v4i4.11954.

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Most staffs agreed, for good reasons of honesty and patient autonomy, that admission of errors is important, but the doctors struggled to decide how it should be done. Most agreed that the socio-legal climate in Nepal, and the possible financial implications, made it difficult to be completely honest. Other strong fears included violence from the patient, damage to the hospital’s reputation and to the reputation of the doctors and possible loss of jobs for nurses. The situation seems to be more or less same in other hospitals of Nepal. It is imperative for every hospital in Nepal to have a clinical ethical committee to look after this matter. There must be appropriate hospital policy on dealing with errors. Hospital staffs need specific training in reporting and disclosing error. DOI: http://dx.doi.org/10.3126/jcmc.v4i4.11954
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3

Schiff, Gordon D. "Medical Error." JAMA 305, no. 18 (May 11, 2011): 1890. http://dx.doi.org/10.1001/jama.2011.496.

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4

Feldman, S. E. "Beyond medical error." Academic Medicine 70, no. 8 (August 1995): 659. http://dx.doi.org/10.1097/00001888-199508000-00001.

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5

Goodman, Gerald R. "Medical device error." Critical Care Nursing Clinics of North America 14, no. 4 (December 2002): 407–16. http://dx.doi.org/10.1016/s0899-5885(02)00022-9.

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6

Gluck, Paul A. "Medical Error Theory." Obstetrics and Gynecology Clinics of North America 35, no. 1 (March 2008): 11–17. http://dx.doi.org/10.1016/j.ogc.2007.12.006.

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7

Brown, Theresa. "Confronting Medical Error." AJN, American Journal of Nursing 120, no. 6 (June 2020): 17. http://dx.doi.org/10.1097/01.naj.0000668696.13024.0e.

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8

Vastag, B. "Medical Error Bill." JAMA: The Journal of the American Medical Association 290, no. 5 (August 6, 2003): 590—b—590. http://dx.doi.org/10.1001/jama.290.5.590-c.

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9

Vastag, B. "Medical Error Reporting." JAMA: The Journal of the American Medical Association 288, no. 14 (October 9, 2002): 1709—a—1709. http://dx.doi.org/10.1001/jama.288.14.1709-a.

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10

Mendonça, Vitor, Thomas Gallagher, and Nicholas Hendryx. "Medical error: concept, characterization and management." Saúde e Sociedade 28, no. 4 (December 2019): 255–66. http://dx.doi.org/10.1590/s0104-12902019180105.

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Abstract The objective of this study is to better understand the tensions involved in the fear of making an error due to the harm and risk this would pose to those involved. This is a qualitative study based on the narratives of the experiences lived by ten acting physicians in the state of São Paulo, Brazil. The concept and characterization of errors were discussed, as well as the fear of making an error, the near misses or error in itself, how to deal with errors and what to do to avoid them. The analysis indicates an excessive pressure in the medical profession for error-free practices, with a well-established physician-patient relationship to facilitate the management of medical errors. The error occurs but the lack of information and discussion often leads to its concealment due to fear of possible judgment by society or peers. The establishment of programs that encourage appropriate medical conduct in the event of an error requires coherent answers for humanization in Brazilian medical science.
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11

Miller, Jacquelyn, C. Ann Vitous, Richard C. Boothman, and Lesly A. Dossett. "Medical error professionals’ perspectives on Inter-system Medical Error Discovery (IMED)." Medicine 99, no. 31 (July 31, 2020): e21425. http://dx.doi.org/10.1097/md.0000000000021425.

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12

Krause, Joan H. "Medical Error as False Claim." American Journal of Law & Medicine 27, no. 2-3 (2001): 181–201. http://dx.doi.org/10.1017/s0098858800011473.

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[I]n appropriate instances, the U.S. Attorney's Office will act to investigate and pursue systemic substandard care issues, notwithstanding a provider's representation of compliance with administrative requirements.Medical error and health care fraud are hot topics these days. Since the Fall 1999 publication of the Institute of Medicine (“IOM”) Report,To Err is Human,medical errors have received a great deal of attention in the popular and academic press. Error reporting bills have been introduced at both the state and federal levels, and industry and government representatives have undertaken a variety of cooperative error-reduction efforts.
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13

Krizek, Thomas J. "When Medical Error Becomes Medical Malpractice." Archives of Surgery 138, no. 4 (April 1, 2003): 447. http://dx.doi.org/10.1001/archsurg.138.4.447.

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14

Mohsin, Syed Umer, Yahya Ibrahim, and Diane Levine. "Teaching medical students to recognise and report errors." BMJ Open Quality 8, no. 2 (June 2019): e000558. http://dx.doi.org/10.1136/bmjoq-2018-000558.

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BackgroundMedical student error reporting can potentially be increased through patient safety education, culture change and by teaching students how to report errors. There is scant literature on what kinds of errors students see during clinical rotations. The authors developed an intervention to better understand what kinds of errors students see and to train them to identify and report errors.MethodsA safety curriculum was delivered during the Medicine clerkship for the academic year 2015–2016. Prior to the workshop, students completed a preintervention survey to determine whether they had reported a clinical error. Subsequently, they participated in an educational workshop. Facilitated discussions about conditions contributing to errors, types of errors, prevention of errors and importance of reporting followed. Students were required to submit a simulated error report about an error they personally observed. An end-of-year survey was sent to students who participated in the curriculum to determine clinical error reporting frequency.ResultsStudents submitted 282 reports. Near miss errors were seen in 64% and adverse events in 36%. National Quality Forum serious events were reported in 14%, including one death. Recommendations to prevent similar events were weak (62%). Students correctly categorised 93% near miss, 88% adverse events, 67% diagnostic, 81% treatment and 78% preventative errors. On the preintervention survey, 8.5% stated they submitted an error report to their clinical site. On the end-of-year survey, 18% confirmed submitting a formal error report.ConclusionTraining students to recognise and report errors can be successfully integrated into a clinical clerkship and impact clinical error reporting.
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15

Mattox, Elizabeth. "Medical Devices and Patient Safety." Critical Care Nurse 32, no. 4 (August 1, 2012): 60–68. http://dx.doi.org/10.4037/ccn2012925.

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Errors related to health care devices are not well understood. Nurses in intensive care and progressive care environments can benefit from understanding manufacturer-related error and device-use error, the principles of human factors engineering, and the steps that can be taken to reduce risk of errors related to health care devices.
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16

&NA;. "Medication errors the most common type of medical error." Reactions Weekly &NA;, no. 825 (October 2000): 2. http://dx.doi.org/10.2165/00128415-200008250-00002.

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17

Spanakis, Spiro G. "Disclosure after medical error." Current Opinion in Anaesthesiology 34, no. 2 (February 10, 2021): 173–75. http://dx.doi.org/10.1097/aco.0000000000000967.

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18

Dykes, Patricia C., Jeffrey M. Rothschild, and Ann C. Hurley. "Recovered Medical Error Inventory." Journal of Nursing Scholarship 42, no. 3 (July 9, 2010): 314–18. http://dx.doi.org/10.1111/j.1547-5069.2010.01356.x.

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19

Bradley, Ciarán, and Karen Brasel. "Disclosing Medical Error #194." Journal of Palliative Medicine 12, no. 6 (June 2009): 555–56. http://dx.doi.org/10.1089/jpm.2009.9614.

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20

Simmons, David A. "Medical Error Root Causes." Journal of Clinical Engineering 25, no. 4 (July 2000): 186. http://dx.doi.org/10.1097/00004669-200025040-00006.

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21

Weingart, S. N. "Epidemiology of medical error." BMJ 320, no. 7237 (March 18, 2000): 774–77. http://dx.doi.org/10.1136/bmj.320.7237.774.

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22

Bell, Sigall K., Tom Delbanco, Lisa Anderson-Shaw, Timothy B. McDonald, and Thomas H. Gallagher. "Accountability for Medical Error." Chest 140, no. 2 (August 2011): 519–26. http://dx.doi.org/10.1378/chest.10-2533.

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23

Hevia, Armando, and Cherri Hobgood. "Medical error during residency." Annals of Emergency Medicine 42, no. 4 (October 2003): 565–70. http://dx.doi.org/10.1067/s0196-0644(03)00399-8.

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24

Gooderham, Peter. "Disclosure of Medical Error." Journal of the Royal Society of Medicine 98, no. 9 (September 2005): 437. http://dx.doi.org/10.1177/014107680509800924.

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25

Weingart, S. N. "Epidemiology of medical error." Western Journal of Medicine 172, no. 6 (June 1, 2000): 390–93. http://dx.doi.org/10.1136/ewjm.172.6.390.

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26

Wiwanitkit, V. "Medical error in surgery." Hernia 14, no. 6 (August 6, 2010): 663. http://dx.doi.org/10.1007/s10029-010-0713-9.

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27

Gianoli, Gerard J. "Medical Error Epidemic Hysteria." American Journal of Medicine 129, no. 12 (December 2016): 1239–40. http://dx.doi.org/10.1016/j.amjmed.2016.06.037.

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28

Robbennolt, Jennifer K. "Apologies and Medical Error." Clinical Orthopaedics and Related Research 467, no. 2 (October 30, 2008): 376–82. http://dx.doi.org/10.1007/s11999-008-0580-1.

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29

Levinson, Wendy, Jensen Yeung, and Shiphra Ginsburg. "Disclosure of Medical Error." JAMA 316, no. 7 (August 16, 2016): 764. http://dx.doi.org/10.1001/jama.2016.9136.

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30

Worthen, Miranda. "After the Medical Error." JAMA 317, no. 17 (May 2, 2017): 1763. http://dx.doi.org/10.1001/jama.2017.0004.

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31

Lester, Helen, and Jonathan Q. Tritter. "Medical error: a discussion of the medical construction of error and suggestions for reforms of medical education to decrease error." Medical Education 35, no. 9 (September 30, 2001): 855–61. http://dx.doi.org/10.1046/j.1365-2923.2001.01003.x.

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32

Wootton, John C. S. "Medical error and medical assistance in dying." Canadian Medical Association Journal 189, no. 1 (January 9, 2017): E31. http://dx.doi.org/10.1503/cmaj.732453.

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33

Graber, Mark A. "Heuristics and medical errors. Part 2: How to make better medical decisions." Russian Family Doctor 25, no. 1 (March 15, 2021): 45–52. http://dx.doi.org/10.17816/rfd62009.

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This publication is a continuation of the article published in the 4th issue of the journal Russian family doctor for 2020 Heuristics, language and medical errors, which described the ways of making medical decisions that can lead to errors in patient management tactics, in particular affect of heuristics / visceral bias, attribution error, frame of reference, availability bias, one-word-one-meaning-fallacy. This article discusses additional sources of diagnostic error, including diagnosis momentum, confirmation bias, representativeness, and premature closure also the conflict that arises from diagnostic uncertainty is discussed. All errors in the tactics and the diagnostic process are illustrated by clinical cases from the personal practice of the author of the article.
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34

POLLACK, CRAIG, CAROL BAYLEY, MICHAEL MENDIOLA, and STEPHEN McPHEE. "Helping Clinicians Find Resolution after a Medical Error." Cambridge Quarterly of Healthcare Ethics 12, no. 2 (April 2003): 203–7. http://dx.doi.org/10.1017/s0963180103002135.

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Clinicians, operating within complex systems, make mistakes, as people do in every human endeavor, and when they do, patients are sometimes harmed. One important question is how we as clinicians can find resolution in the wake of an error. The published literature has divided errors into those caused by “systems” and by “individuals.” But whereas both “systems” and “individual” approaches are important in understanding the cause of an error, neither alone can fully lead to resolution once an error has occurred. Instead, both are necessary to understand, resolve, and prevent errors.
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35

Stoyanova, Rumyana G., Ralitsa D. Raycheva, and Rositsa Tz Dimova. "Economic aspects of medical errors." Folia Medica 54, no. 1 (October 1, 2012): 58–64. http://dx.doi.org/10.2478/v10153-011-0079-5.

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ABSTRACT The critical problem of medical errors and the associated costs has recently been increasingly in the focus of attention of a number of world renowned experts. In the present article we review in detail and analyse the economic aspects of this problem. A methodology to assess the cost of medical errors and an algorithm for their prevention are presented. The cost of a medical error and the expenses required to avoid and prevent it are compared using graphical analysis of the prevention cost curve and the medical error compensation damages cost curve.
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36

Kiesewetter, Isabel, Karen D. Könings, Moritz Kager, and Jan Kiesewetter. "Undergraduate medical students’ behavioural intentions towards medical errors and how to handle them: a qualitative vignette study." BMJ Open 8, no. 3 (March 2018): e019500. http://dx.doi.org/10.1136/bmjopen-2017-019500.

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ObjectivesIn undergraduate medical education, the topics of errors in medicine and patient safety are under-represented. The aim of this study was to explore undergraduate medical students’ behavioural intentions when confronted with an error.DesignA qualitative case vignette survey was conducted including one of six randomly distributed case scenarios in which a hypothetical but realistic medical error occurred. The six scenarios differed regarding (1) who caused the error, (2) the presence of witnesses and (3) the consequences of the error for the patient. Participants were asked: ‘What would you do?”. Answers were collected as written free texts and analysed according to qualitative content analysis.SettingStudents from German medical schools participated anonymously through an online questionnaire tool.ParticipantsAltogether, n=159 students answered a case scenario. Participants were on average 24.6 years old (SD=7.9) and 69% were female. They were undergraduate medical students in their first or second year (n=27), third, fourth or fifth year (n=107) or final year (n=21).ResultsDuring the inductive coding process, 19 categories emerged from the original data and were clustered into four themes: (1) considering communication; (2) considering reporting; (3) considering consequences; and (4) emotional responsiveness. When the student him/herself caused the error in the scenario, participants did mention communication with colleagues and taking preventive action less frequently than if someone else had caused the error. When a witness was present, participants more frequently mentioned disclosure of the error and taking actions than in the absence of a witness. When the outcome was significant to the patient, participants more often showed an emotional response than if there were no consequences.ConclusionsThe study highlights the importance of coping strategies for healthcare professionals to adequately deal with errors. Educators need to introduce knowledge and skills on how to deal with errors and emotional preparedness for errors into undergraduate medical education.
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37

Poudel, R. S., R. M. Piryani, S. Shrestha, A. Prajapati, and B. Adhikari. "Prescription errors and pharmacist intervention at outpatient pharmacy of Chitwan Medical College." Journal of Chitwan Medical College 5, no. 2 (August 14, 2015): 20–24. http://dx.doi.org/10.3126/jcmc.v5i2.13150.

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Prescribing errors are harmful to the patients. The role of pharmacist in reducing potential harm from prescription errors have been highlighted by several studies. This study aimed to evaluate the drug related prescription error and pharmacist intervention at outpatient pharmacy of Chitwan Medical College Teaching Hospital. A cross-sectional study was conducted in the outpatient Pharmacy of Chitwan Medical College Teaching Hospital from November 2014 to December 2014. The outpatient pharmacist randomly selected 5000 prescription and checked for drug related prescription error using prescription error checklist. The pharmacist discussed the prescription errors with the prescriber. The prescriptions that were corrected by the prescribers were considered as pharmacist intervened prescriptions (pharmacist intervention). Descriptive statistics including Chi-square test were done for statistical analysis using IBM-SPSS version 20. Out of 5000 prescriptions 176 drug related prescription error was found. The commonest error was dose and dosing frequency error (39.2%), duplication (33.5%) and dosage form related error (19.3%). Most of the prescription errors were noted while prescribing antimicrobial drugs (27.8%), proton pump inhibitors (15.9%) and NSAIDs (12.5%). The pharmacist’s recommendation was accepted by prescriber in 90.3% of prescription . Chi-square test showed significant association (p=0.019) between prescription errors and pharmacist intervention. Pharmacist intervention can reduce the drug related prescription error, so the pharmacist and clinician need to strongly work together for reducing overall prescriptions error.
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38

Seiler, Fritz A. "Error Propagation for Large Errors." Risk Analysis 7, no. 4 (December 1987): 509–18. http://dx.doi.org/10.1111/j.1539-6924.1987.tb00487.x.

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39

Kohen, N., E. Morgenfeld, G. Ernesto, A. Negro, M. Muiño, D. Juarez, S. Aguirre, D. Santillan, E. Rivarola, and F. G. Gercovich. "Medical error prevention: The role of oncological nursing." Journal of Clinical Oncology 27, no. 15_suppl (May 20, 2009): 6591. http://dx.doi.org/10.1200/jco.2009.27.15_suppl.6591.

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6591 Background: The medical care of oncological patients is a multidisciplinary task. The nurse is a key member of the team. The aim of this study is to analyze the incidence rate and the type of intravenous chemotherapy prescription errors detected by the nurses in the the ambulatory setting at the IOHM in a 3 months period. Methods: The intravenous chemotherapy treatments (tx) prescribed by the IOHM's staff (14 oncologists and 4 onco-hematologists) between Aug 1, 2008 and Nov 1, 2008, were analyzed. A database was prospectively built with the following variables: attending physician, diagnosis, treatment cycle, drug, dosage, time of perfusion, type of error detected, and potential harm from it. Frequency tables were established for the type of error. The correlation between the rate of errors by prescribing physician and his expertise, weekly hours of work at the institution, number of patients under his care and number of consults were also studied. Results: A total of 5,015 tx administered to 2,492 pt were evaluated (mean of 2.1 tx per pt, range 1–5). The most common cancer diagnoses were breast (20%), colon (16%), lung (10%), and lymphoma (7%). Forty-five medical prescription errors before administration of treatment were found. There were no errors found in the preparation and administration of treatment. Of the 45 errors detected, 18 were related to drug selection (in 2 cases the error could lead to serious complications). Twenty seven errors were related to a dosage mistake (3 cases with serious potential harm). The frequency of medical errors between the attending physicians did not differ statistically (Fisher Exact Test 0.082) and due to the low error rate, none of the other variables could be properly studied. Conclusions: 1. Specialized nursing is a key element in the safety of the patient and the prevention of malpractice, 2. The rate of errors in this population is 0.9% (45 errors out of 5,015) and the rate of potentially serious harm to the patient is 1/1000 tx.; 3) All errors were corrected before drug administration. No significant financial relationships to disclose.
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40

Mason, Jordan. "Confessional Approach to Disclosure of Medical Error." Christian bioethics: Non-Ecumenical Studies in Medical Morality 27, no. 2 (June 8, 2021): 203–22. http://dx.doi.org/10.1093/cb/cbab006.

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Abstract Recent literature on the ethics of medical error disclosure acknowledges the feelings of injustice, confusion, and grief patients and their families experience as a result of medical error. Substantially less literature acknowledges the emotional and relational discomfort of the physicians responsible or suggests a meaningful way forward. To address these concerns more fully, I propose a model of medical error disclosure that mirrors the theological and sacramental technique of confession. I use Aquinas’ description of moral acts to show that all medical errors are evil, and some accidental medical errors constitute venial sins; all sin and evil should be confessed. As Aquinas urges confession for sins, here I argue that confession is necessary to restore physicians to the community and to provide a sense of absolution. Even mistakes for which physicians are not morally culpable ought to be confessed in order to heal the physician–patient relationship and to address feelings of professional distress. This paper utilizes an Episcopal theology of confession that affirms verbal admission and responsibility-taking as freeing and relationally restoring acts, arguing that a confessional stance toward medical error both leads to better outcomes in physician–patient relationships and is more compassionate toward physicians who err.
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41

Aghighi, Negar, Jalal Poorolajal, and Shirin Rezaie. "Barriers to medical error reporting." International Journal of Preventive Medicine 6, no. 1 (2015): 97. http://dx.doi.org/10.4103/2008-7802.166680.

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42

Karlsen, Kristine A., Thomas J. Hendrix, and Maureen OʼMalley. "Medical Error Reporting in America." Quality Management in Health Care 18, no. 1 (January 2009): 59–70. http://dx.doi.org/10.1097/01.qmh.0000344594.48510.82.

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43

Allhoff, Fritz. "Medical Error and Moral Luck." Kennedy Institute of Ethics Journal 29, no. 3 (2019): 187–203. http://dx.doi.org/10.1353/ken.2019.0022.

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44

Winter, George F. "Guilt, forgiveness and medical error." British Journal of Midwifery 27, no. 3 (March 2, 2019): 145. http://dx.doi.org/10.12968/bjom.2019.27.3.145.

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Edrees, H., and F. Federico. "Supporting clinicians after medical error." BMJ 350, apr15 6 (April 15, 2015): h1982. http://dx.doi.org/10.1136/bmj.h1982.

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Manji, Rizwan A., Hilary P. Grocott, and Rakesh C. Arora. "Medical Error and “Psycho-Physiology”." Seminars in Thoracic and Cardiovascular Surgery 31, no. 3 (2019): 397–98. http://dx.doi.org/10.1053/j.semtcvs.2019.05.011.

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Clay, Alison S. "Medical Error. The Personal Cost." Annals of the American Thoracic Society 10, no. 6 (December 2013): 690–92. http://dx.doi.org/10.1513/annalsats.201307-227ot.

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Van Cott, Harold P. "Human Error and Medical Devices." Proceedings of the Human Factors Society Annual Meeting 35, no. 10 (September 1991): 683. http://dx.doi.org/10.1177/154193129103501022.

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Flemons, W. "Patient safety and "medical error"." Canadian Medical Association Journal 186, no. 2 (December 9, 2013): 141. http://dx.doi.org/10.1503/cmaj.130962.

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Almassi, Ben. "Medical Error and Moral Repair." International Journal of Applied Philosophy 32, no. 2 (2018): 143–54. http://dx.doi.org/10.5840/ijap201926103.

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