====== Preventable medical error ======

The [[Institute of Medicine]]’s landmark report, To Err is Human: Building a Safer Health System, brought into focus the preventable medical errors that are negatively affecting patient outcomes
((Kohn LT, Corrigan J, Donaldson MS. To err is human : building a safer health system. Washington, D.C.: National Academy Press; 2000.)).

Preventable medical errors in the neurosurgical field are of particular interest, given the
((Yang I, Ung N, Nagasawa DT, et al. Recent advances in the patient safety and quality initiatives movement: implications for neurosurgery. Neurosurgery clinics of North America. 2015;26(2):301-315, xi.))
((Stone S, Bernstein M. Prospective error recording in surgery: an analysis of 1108 elective neurosurgical cases. Neurosurgery. 2007;60(6):1075-1082.))
((Fargen KM, Friedman WA. The science of medical decision making: neurosurgery, errors, and personal cognitive strategies for improving quality of care. World Neurosurg. 2014;82(1-2):e21- 29.))
potentially fatal consequences. Among the factors contributing to this problem is that variance
((Teixeira PGR, Inaba K, Hadjizacharia P, et al. Preventable or potentially preventable mortality at a mature trauma center. J Trauma. 2007;63(6):1338-1347.))
((Rolston JD, Bernstein M. Errors in neurosurgery. Neurosurgery clinics of North America. 2015;26(2):149-155.)).

Among the factors contributing to this [[problem]] is that variance between [[provider]]s exposes the [[healthcare system]] to inefficiencies and worse [[health]] [[outcome]]s
((James B. Information system concepts for quality measurement. Med Care. 2003;41(1 Suppl):I71-79.))
((Nordin-Johansson A, Asplund K. Randomized controlled trials and consensus as a basis for interventions in internal medicine. J Intern Med. 2000;247(1):94-104.))
((Suarez-Varela MM, Llopis-Gonzalez A, Bell J, Tallon-Guerola M, Perez-Benajas A, Carrion- Carrion C. Evidence based general practice. Eur J Epidemiol. 1999;15(9):815-819.))
((Ellis J, Mulligan I, Rowe J, Sackett DL. Inpatient general medicine is evidence based. A-Team, Nuffield Department of Clinical Medicine. Lancet. 1995;346(8972):407-410.))
((Goitein L, James B. Standardized best practices and individual craft-based medicine: A conversation about quality. JAMA Intern Med. 2016;176(6):835-838.)).

There is a need for the systematic accumulation of [[evidence]] to support [[clinical decision-making]]
((Djulbegovic B, Guyatt GH. Progress in evidence-based medicine: a quarter century on. Lancet. 2017;390(10092):415-423.))

[[Quality]].

[[Debriefing]].

[[Error documentation]]

[[Adverse event]] prevention