A Tale of Two Stories
National Patient Safety Foundation

Report from a Workshop on Assembling the Scientific Basis for Progress on Patient Safety

Table of Contents

Executive Summary

Cover     Author and Sponsor Information Preface Table of Contents Tables and Figures Acknowledgements Prelude

Introduction

Health Care After Its "Three Mile Island"

Day One - Contrasting Cases     Celebrated Accidents The View of Patient Safety from Celebrated Cases Uncelebrated Cases: The Second Story #1: Bile duct injuries during laparoscopic cholecystectomy #2: Antibody misidentification and transfusion reactions #3: Drug misadministrations via computerized infusion devices in the operating room

Day Two - Incident Reporting and Analysis     Lessons from the Aviation Safety Reporting System (ASRS) Incident Classification and Analysis Learning from Incidents and Accidents   Conclusions References

Appendices A. List of Participants B. Lessons Learned From Incident Reporting in Aviation (text of talk given by Charles Billings on December 16, 1997) C. List of Sourcebook Materials Distributed to Workshop Participants

 
  

Tables and Figures

Tables
Table 1	"Celebrated" medical accidents
Table 2	The sequence of events in the investigation of four operating room incidents involving misadministrations via an infusion device.
Figures
Figure 1	The view of patient safety based on celebrated cases.
Figure 2	Hindsight does not equal foresight.
Figure 3	The blunt end of a complex system controls the resources and constraints that confront the practitioner at the sharp end
Figure 4	A stage in an antibody identification problem using an enhanced electronic version of the original paper form with computer-based critiquing.
Figure 5	Protocol describing the interaction between anesthesiologists and an infusion device during an operating room incident.

 

The complete report is also available in Microsoft Word, WordPerfect, and Adobe Acrobat file formats for download. MS Word 97 format MS Word 95 format WordPerfect 5 format Adobe Acrobat format

 

Copyright 1998 National Patient Safety Foundation at the AMA Prepared for Web publication by Annenberg Center for Health Sciences