Adverse events are incidents in which a patient is unintentionally harmed by medical
treatment. Awareness while under anaesthetic, deaths during surgery, and missed cases of …

The success of incident reporting in improving safety, although obvious in aviation and other
high-risk industries, is yet to be seen in health-care systems. An incident reporting system …

Unconsciousness is a fundamental component of general anesthesia (GA), but
anesthesiologists have no reliable ways to be certain that a patient is unconscious. To …

This chapter examines issues surrounding human performance at the sharp end, including
those described as errors and those considered expert. It provides an introduction to the …

Background In a sample of 30,195 randomly selected hospital records, we identified 1133
patients (3.7 percent) with disabling injuries caused by medical treatment. We report here an …

FOR YEARS, medical and nursing students have been taught Florence Nightingale's dictum—
first, do no harm. 1 Yet evidence from a number of sources, reported over several decades …

Objective.—To identify and evaluate the systems failures that underlie errors causing
adverse drug events (ADEs) and potential ADEs. Design.—Systems analysis of events from …

Pilots and doctors operate in complex environments where teams interact with technology.
In both domains, risk varies from low to high with threats coming from a variety of sources in …

Human error is cited over and over as a cause of incidents and accidents. The result is a
widespread perception of a'human error problem', and solutions are thought to lie in …

The historical roots of simulation might be described with the broadest definition of medical
simulation:“an imitation of some real thing, state of affairs, or process” for the practice of …