Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems

doi:10.1136/bmj.320.7237.759

BMJ 2000;320:759-763 ( 18 March )

Clinical review

Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems

Paul Barach, clinical fellow, Stephen D Small, assistant anaesthetist.

Department of Anesthesia and Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA

Correspondence to: P Barach pbarach@etherdome.mgh.harvard.edu

The first 150 words of the full text of this article appear below.

Reducing mishaps from medical management is central to efforts to improve quality and lower costs in health care. Nearly 100000 patients are estimated to die preventable deaths annuallyin hospitals in the United States, with many more incurring injuriesat an annual cost of $9 billion. Underreporting of adverse eventsis estimated to range from 50%-96% annually.^1-3 This annual tollexceeds the combined number of deaths and injuries from motorand air crashes, suicides, falls, poisonings, and drownings.⁴Many stakeholders in health care have begun to work together toresolve the moral, scientific, legal, and practical dilemmas ofmedical mishaps. To achieve this goal, an environment fosteringa rich reporting culture must be created to capture accurate anddetailed data about nuances ofcare.

Outcomes in complex work depend on the integration of individual, team, technical, and organisational factors. ⁵ ⁶ A continuumof cascade effects exists from apparently trivial incidents . . . [Full text of this article]

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Facing up to medical error
BMJ 2000 320: 0. [Full Text] [PDF]

Facing up to medical error
BMJ 2000 320: 0. [Full Text] [PDF]

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