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Kelly Malcom, HBNS Editor and Becky Ham, Science Writer A 1999 report from the Institute of Medicine (IOM) revealed just how pervasive and harmful medical errors king drew medical magnet are in American health care, killing an estimated 98,000 patients each year. Although

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the IOM report drew significant attention to medical errors, studies suggest that errors remain common more than a decade

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later. A 2010 study, conducted by the U.S. Department of Health and Human Services’ Office of the Inspector General, found that an estimated 13.5 percent-about 1 in 7-of hospitalized Medicare patients experienced

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adverse events during their hospital stays, and an August 2011 study in the journal Health Affairs suggested that as many as one in three hospitalized patients could be harmed or killed by medical error. “Medicine in some ways is a victim of its own success,” says Peter Pronovost, M.D., professor in the departments of anesthesiology and critical care medicine and surgery and director of drew medical school the Armstrong Institute for Patient Safety at Johns Hopkins Medical School. “Many years ago, the only therapies we had were what the doctor held in his black bag. Now we have amazingly complex treatments; we can put a new hip in you or operate on your heart. But all of that complexity also added risk.” Tracking and reducing medical errors are part of widespread efforts to improve patient safety. “Many of the negative patient safety events are related to systems and how people operate within them,” says Jeff Brady, M.D., of the U.S. Health and Human Services’ Agency for Research and Quality (AHRQ). He refers to slices of Swiss cheese to describe how errors might happen. “There are flaws within health care systems like the holes in Swiss cheese. Normally, when there’s a hole, there’s a check in another part of the system that will prevent something from happening. A patient safety event often occurs when the normal system of checks and balances fails in an unfortunately coordinated way.” Errors are often the result of poor coordination within the health care system and poor communication on the part of physicians,

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MORE LinkedIn StumbleUpon Google + Cancel This month the British Medical Journal published a report by Johns Hopkins researchers showing that preventable medical error is the third leading cause of death in

Commands Skip to main content This site is best viewed with Internet Explorer http://www.ihi.org/education/ihiopenschool/resources/Pages/Activities/AHRQCaseStudyWrongShotErrorDisclosure.aspx version 8 or greater. Check your browser compatibility mode if you http://www.huffingtonpost.com/michael-drew/medical-mistakes_b_2017788.html are using Internet Explorer version 8 or greater. Log In / Register Extranet Newsletter Sign Up Newsletter Sign Up close Sign up for IHI's Email Services updating ... Blog Careers IHI Home Overview Online Courses Community Project-Based Learning Home Overview Online Courses Courses drew medical Overview First-Time Visitors Return to MY COURSES Subscription Options Certificates & CEUS Curriculum Integration Activities Library Community Community Overview Chapter Network Faculty Network Blog Activities & Exercises Newsletter Sign Up Project-Based Learning Experiential Learning Overview Leadership & Organizing Quality Improvement in Action Home / Education / IHI Open School / Activities / Activities / drew medical school The Wrong Shot: Error Disclosure (AHRQ) Case Study Activities Activities Video Library Case Studies Games and Exercises Patient Stories Publishing Your Work Other Resources IHI LR Wide The Wrong Shot: Error Disclosure (AHRQ) Page Content Case Study from AHRQ WebM&M Learning Objectives: At the end of this acticity, you will be able to: Describe the rationale for disclosing harmful errors to patients. Describe the specific information that patients want disclosed following a harmful error. Define the "disclosure gap" and the barriers that contribute to the difficulty health care workers experience in disclosing errors to patients. Recognize the emotional impact that errors have on health care workers and how these emotions can impair the disclosure process. List specific steps that institutions can take to enhance the disclosure of harmful errors to patients. Description: A child is mistakenly vaccinated for hepatitis A, rather than B. Despite forthright disclosure and no evident harm to the child, the father becomes incredibly

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