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 1).
Preventable medical errors in the neurosurgical field are of particular interest, given the 2) 3) 4) potentially fatal consequences. Among the factors contributing to this problem is that variance 5) 6).
Among the factors contributing to this problem is that variance between providers exposes the healthcare system to inefficiencies and worse health outcomes 7) 8) 9) 10) 11).
There is a need for the systematic accumulation of evidence to support clinical decision-making 12)
Adverse event prevention
1)
Kohn LT, Corrigan J, Donaldson MS. To err is human : building a safer health system. Washington, D.C.: National Academy Press; 2000.
2)
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.
3)
Stone S, Bernstein M. Prospective error recording in surgery: an analysis of 1108 elective neurosurgical cases. Neurosurgery. 2007;60(6):1075-1082.
4)
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.
5)
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.
6)
Rolston JD, Bernstein M. Errors in neurosurgery. Neurosurgery clinics of North America. 2015;26(2):149-155.
7)
James B. Information system concepts for quality measurement. Med Care. 2003;41(1 Suppl):I71-79.
8)
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.
9)
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.
10)
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.
11)
Goitein L, James B. Standardized best practices and individual craft-based medicine: A conversation about quality. JAMA Intern Med. 2016;176(6):835-838.
12)
Djulbegovic B, Guyatt GH. Progress in evidence-based medicine: a quarter century on. Lancet. 2017;390(10092):415-423.