AMA Journal of Ethics®

Illuminating the art of medicine

Journal of Ethics Header

AMA Journal of Ethics®

Illuminating the art of medicine

Virtual Mentor. March 2004, Volume 6, Number 3.

Suggested Reading and Resources

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Resources on Patient Safety and Medical Error

Further Reading

  • Opinion 9.032 Reporting Adverse Drug or Device Events. Code of Medical Ethics 2008-2009 Edition. Chicago, IL: American Medical Association; 2008:302-303.
  • Opinion 10.02 Patient Resposibilities. Code of Medical Ethics 2008-2009 Edition. Chicago, IL: American Medical Association; 2008:351-353.
  • American Hospital Association. AHA Guide to Computerized Order Applications. Washington, DC: American Hospital Association; 2000.
  • Banja J. Moral courage in medicine—disclosing medical error. Bioethics Forum. 2001;17:7-11.
  • Barach P, Small SD. Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems. BMJ. 2000;320:759-763.
  • Bates DW, Teich JM, Lee J, et al. The impact of computerized physician order entry on medication error prevention. J Am Med Inform Assoc. 1999;6:313-21.
  • Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 4th ed. New York: Oxford University Press; 1994.
  • Benbassat J, Pilpel D, Tidhar M. Patients' preferences for participation in clinical decision making: a review of published surveys. Behav Med. Summer 1998;24:81-88.
  • Berg JW, Appelbaum PS, Lidz CW, Parker LS. Informed Consent: Legal Theory and Clinical Practice. 2nd ed. New York: Oxford University Press; 2001.
  • Berlinger N. Avoiding cheap grace: medical harm, patient safety, and the culture(s) of forgiveness. Hastings Center Report. 2003;33:28-36.
  • Blendon RJ, DesRoches CM, Brodie M, et al. Views of practicing physicians and the public on medical errors. N Engl J Med. 2002;347:1933-1940.
  • Brennan T, Berwick D. New Rules: Regulation, Markets, and the Quality of American Health Care. San Francisco: Jossey-Bass; 1995.
  • Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med. 1991;324: 370-6.
  • Brennan TA. The Institute of Medicine Report on medical errors—could it do harm? N Engl J Med. 2000;342:1123-1125.
  • Burke JP. Infection control—a problem for patient safety. N Engl J Med. 2003;48:651-56.
  • Caine v Hardy, 943 F2d 1406, 1412 (5th Cir 1991) (en banc).
  • Centers for Medicare & Medicaid Services Web site. Quality initiatives. Accessed February 10, 2004.
  • Christensen JF, Levinson W, Dunn PM. The heart of darkness: the impact of perceived mistakes on physicians. J Gen Intern Med. 1992;7:424-431.
  • Clinical Advisory Board. Computerized Physician Order Entry—Lessons From Pioneering Institutions. Washington, DC: Clinical Advisory Board; 2001.
  • Cohen JR. Apology and organizations: exploring an example from medical practice. Fordham Urban Law Journal. 2000;27:1447-1482.
  • Cooper JB, Gaba D. No myth: anesthesia is a model for addressing patient safety [editorial]. Anesthesiology. 2002;97:1325-1337.
  • Daubert v Merrill Dow Pharmaceuticals, Inc, 509 US 579, 113 S Ct 2786, 125 L Ed 2d 469, 61 USLW 4805, 1993 US LEXIS 4408, June 28, 1993.
  • Davidoff F. Shame: the elephant in the room; managing shame is important for improving health care. BMJ. 2002;324:623-624.
  • Davis B, Appleby J. Medical mistakes 8th top killer. USA Today. November 30, 1999:1A.
  • Deber RB, Kraetschmer N, Irvine J. What role do patients wish to play in treatment decision making? Arch Intern Med. 1996;156:1414-1420.
  • Dentzer S. Media mistakes in coverage of the Institute of Medicine's error report. Eff Clin Pract. Nov-Dec 2000;3:305-8. Accessed January 30, 2004.
  • Editors Choice. Informed compliance. BMJ. 2002;324:0h.
  • Emanuel EJ, Emanuel LL. Proxy decision making for incompetent patients. An ethical and empirical analysis. JAMA. 1992;267:2067-2071.
  • Frankel A, Gandhi TK, Bates DW. Improving patient safety across a large integrated health care delivery system. Int J Quality Health Care. 2003;15:i31-i40.
  • Gaba D, Howard SH. Human work environment and simulators. In: Miller RD, ed. Anesthesia. 6th ed. New York: Churchill Livingstone; August 2004.
  • Gallagher TH, Waterman AD, Ebers AG, Fraser VJ, Levinson W. Patients' and physicians' attitudes regarding the disclosure of medical errors. JAMA. 2003;289:1001-1007.
  • Galvin R, Milstein A. Large employers' new strategies in health care. N Engl J Med. 2002;347:939-941.
  • Gawande A. Complications: A Surgeon's Notes on an Imperfect Science. New York, NY: Henry Holt and Company; 2002:11-34.
  • Gilbert v Homar, 520 US 924, 138 L Ed 2d 120, 117 S Ct 1807 (1997).
  • Halbach MM, Spann CO, Egan G. Effect of sleep deprivation on medical resident and student cognitive function: a prospective study. Am J of Obstet Gynecol. 2003;185:1198-1201
  • Halm EA, Fine MJ, Kapoor WN, Singer DE, Marrie TJ, Siu AL. Instability on hospital discharge and the risk of adverse outcomes in patients with pneumonia. Arch Intern Med. 2002;162:1278-84.
  • Hayward RA, Hofer TP. Estimating hospital deaths due to medical errors: preventability is in the eye of the reviewer. JAMA. 2001;286:415-420.
  • Health Care Quality Improvement Act of 1986, Pub L No 99-660, 100 Stat 3784 (codified as amended at 42 USC §§ 11101-11152).
  • Hevia A, Hobgood C. Medical error during residency: to tell or not to tell. Ann Emerg Med. 2003;42:565-570.
  • Hobgood C, Peck CR, Gilbert B, Chappell K, Zou B. Medical errors—what and when: what do patients want to know? Acad Emerg Med. 2002;9:1156-1161.
  • Howard SK, Gaba DM, Rosekind MR, Zarcone VP. The risks and implications of excessive daytime sleepiness in resident physicians. Acad Med. 2002;77:1019-25.
  • Hupert N, Lawthers AG, Brennan TA, Petersen LM. Processing the tort deterrent signal: a qualitative study. Soc Sci Med. 1996;43:1-11.
  • Institute of Medicine, Committee on Quality of Health Care in America. Crossing the Quality Chasm: a New Health System for the 21st Century. Washington DC: National Academy Press; 2001.
  • Issenberg SB, McGaghie WC, Hart IR, et al. Simulation technology for health care professional skills training and assessment. JAMA. 1999;282:861-6.
  • Joint Commission on Accreditation of Health Care Organizations. Revisions To joint Commission Standards in Support of Patient Safety and Medical Health Care Error Reduction. July 1, 2001. Accessed February 23, 2004.
  • Joint Commission on Accreditation of Healthcare Organizations: Standards MS 2166. Accreditation Manual For Hospitals. 1994: 66-72.
  • Jonsen AR, Siegler M, Winslade WJ. Clinical Ethics. 5th ed. Chicago, Ill: McGraw-Hill; 2002:163.
  • Jonsen AR. A Short History of Medical Ethics. New York: Oxford University Press; 2000:3.
  • Kamerow DB. Clinical evidence: creation, assessment, and implementation. Presented at: the Agency for Health Care Policy and Research's conference Translating Evidence Into Practice: What Do We Know? What Do We Need? July 21-23, 1997; Washington, DC. Accessed February 17, 2004.
  • Kinkade RG. Human Factors Primer for Nuclear Utility Managers. Pub no NP-5714. Palo Alto: Electric Power Research Institute; 1988.
  • Kohn LT, Corrigan JM, Donaldson MS, eds; Committee on Quality of Health Care in America, Institute of Medicine. To Err is Human: Building a Safer Health System. Washington DC: National Academies Press; 2000.
  • Leape LL. Error in medicine. JAMA. 1994;272:1851-1857.
  • Leape LL. Institute of Medicine medical error figures are not exaggerated. JAMA. 2000;284:95-97.
  • Liang BA. The adverse event of unaddressed medical error. J Law Med Ethics. 2001;29:346-368.
  • Liang BA. Deselection under Harper v Healthsource: a blow for maintaining patient-physician relationships in the era of managed care? Notre Dame L Rev. 1997;72:799-861.
  • Liang BA. Error disclosure for quality improvement: authenticating a team of patients and providers to promote patient safety. In: Sharpe VA, ed. Promoting Patient Safety: An Ethical Basis for Policy Deliberation. Washington DC: Georgetown University Press; 2004 (in press).
  • Liang BA. Error in medicine: legal impediments to US reform. J Health Politics Policy Law. 1999;24:27-58.
  • Liang BA. Patient injury incentives in law. Yale Law Policy Rev. 1998;17:1-93.
  • Liang BA. Promoting patient safety through reducing medical error: a paradigm of cooperation between patient, physician, and attorney. SIU Law J. 2000;24:541-568.
  • Liang BA. Risk of reporting sentinel events. Health Affairs. 2000;19:112-120.
  • Liang BA. A system of medical error disclosure. Qual Safety Health Care. 2002;11:64-68.
  • Liang BA, Small SD. Communicating about care: addressing federal-state issues in peer review and mediation to promote patient safety. Houston J Health L Policy. 2003;3:219-64.
  • Lo B. Resolving ethical dilemmas: a guide for clinicians. 2nd ed. Philadelphia: Lippincott Williams & Wilkins; 2000.
  • Maurino D, Reason J, Johnston N, Lee R. Beyond Aviation Human Factors. Aldershot, UK: Ashgate; 1995.
  • McCall SL. A hospital's liability for denying, suspending and granting staff privileges. Baylor L Rev. 1980;175:32.
  • McDonald CJ, Weiner M, Hui SL. Deaths due to medical errors are exaggerated in Institute of Medicine report. JAMA. 2000;284:93.
  • MedicalErrorReduction.com Web site
  • Medicare Quality Improvement Community Web site. Surgical infection prevention project description. Accessed February 10, 2004.
  • National Heart, Lung, and Blood Institute Web site. National asthma education and prevention program. Accessed February 10, 2004.
  • Newman MC. The emotional impact of mistakes on family physicians. Arch Fam Med. 1996;5:71-75.
  • Northeast Georgia Radiological Associates, PC v Tidwell, et al., 607 F 2d 507 at 511.
  • Novack DH, Detering BJ, Arnold R, Forrow L, Ladinsky M, Pezzullo JC. Physicians' attitudes toward using deception to resolve difficult ethical problems. JAMA. 1989;261:2980-2985.
  • Office of Inspector General. Managed Care Organization Nonreporting to the National Practitioner Data Bank. Washington, DC: DHHS OIG Report OEI-01-99-00690; May 2001.
  • Outrageous medical mistakes [transcript]. "The Oprah Winfrey Show." October 6, 2003. Accessed January 30, 2004.
  • Patel v Midland Memorial Hospital, 298 F3d 333; 2002 US App LEXIS 13834.
  • Patient Safety and Quality Improvement Act. HR 663. February 11, 2003. Accessed February 19, 2004.
  • Patient Safety and Quality Improvement Act. S 720 IS. March 26, 2003. Accessed February 19, 2004.
  • Premier Safety Institute Web site. Basic patient safety program tool kit for "getting started". Accessed February 10, 2004.
  • Reason J. Human Error. New York: Cambridge University Press; 1990.
  • Reason JT. Managing the Risks of Organizational Accidents. Aldershot, England: Ashgate Publishing Company; 1997.
  • Rosner F, Berger JT, Kark P, Potash J, Bennett AJ. Disclosure and prevention of medical errors. Committee on Bioethical Issues of the Medical Society of the State of New York. Arch Intern Med. 2000;160:2089-2092.
  • Section 1160, California Evidence Code; 2000.
  • Sharpe VA. Behind closed doors: accountability and responsibility in patient care. J Med Phil. 2000;25:28-47.
  • Shekelle PG. Why don't physicians enthusiastically support quality improvement programs? Qual Safety Health Care. 2002;11:6.
  • Skelton JR, Wearn AM, Hobbs FD. "I" and "we": a concordancing analysis of how doctors and patients use first person pronouns in primary care consultations. Fam Prac. 2002;19:484-488.
  • Small SD, Wuerz RC, Simon R, Shapiro N, Conn A, Setnik G. Demonstration of high-fidelity simulation team training for emergency medicine. Acad Emerg Med. 1999;6:312-23.
  • Stewart JB. Blind Eye: How the Medical Establishment Let a Doctor Get Away with Murder. New York: Simon and Shuster; 1999.
  • Tex Civ Prac & Rem Code Ann sec 73 005 (Vernon 2001).
  • The Leapfrog Group Web site. Accessed February 10, 2004.
  • The Leapfrog Group Web site. Survey results. Accessed February 17, 2004.
  • Thomas EJ, Studdert DM, Burstin HR, et al. Incidence and types of adverse events and negligent care in Utah and Colorado. Med Care. March 2000;38:261-71.
  • Tito F. Compensation and Professional Indemnity in Health Care. Review of Professional Indemnity Arrangements for Health Care Professionals. Canberra: Commonwealth Department of Human Services and Health; 1994.
  • UK Department of Health. An Organisation with a Memory: Report of an Expert Group on Learning from Adverse Events in the NHS. London, England: National Health Service; 2000.
  • US General Accounting Office. National Practitioner Data Bank: Major Improvements Needed to Enhance Data Bank's Reliability. GAO Report 01-130. Washington, DC: US General Accounting Office; November 2000.
  • US Nuclear Regulatory Commission. Guidelines of Control Room Design Reviews. Pub no NUREG-0700. Bethesda: US Nuclear Regulatory Commission; 1981.
  • Veasey S, Rosen R, Barzansky B, Rosen I, Owens J. Sleep loss and fatigue in residency training: a reappraisal. JAMA. 2002;288:1116-24.
  • Vincent CA, Pincus T, Scurr JH. Patients' experience of surgical accidents. Qual Health Care. June 1993;277-82.
  • Vincent JL. Information in the ICU: are we being honest with our patients? The results of a European questionnaire. Intensive Care Med. 1998;24:1251-1256.
  • Waters TM, Parsons J, Warnecke R, Almagor O, Budetti PP. How useful is the information provided by the National Practitioner Data Bank? Jt Comm J Qual Saf. 2003;29:416-424.
  • Waters TM, Studdert DM, Brennan TA, et al. Impact of the National Practitioner Data Bank on resolution of malpractice claims. Inquiry. 2003;40:283-294.
  • Weick KE, Sutcliffe KM. Managing the Unexpected: Assuring High Performance in an Age of Complexity. San Francisco, CA: Jossey-Bass; 2001.
  • Wilson LL. Quality management: prevention is better than cure. Australian Clin Rev. 1993;13:75-82.
  • Witman AB, Parc DM, Hardin SB. How do patients want physicians to handle mistakes? A survey of internal medicine patients in an academic setting. Arch Intern Med. 1996;156:2565-2569.
  • Wu AW, Cavanaugh TA, McPhee SJ, Lo B, Micco GP. To tell the truth: ethical and practical issues in disclosing medical mistakes to patients. J Gen Int Med. 1997;12:770-775.
  • Wu AW, Folkman S, McPhee SJ, Lo B. Do house officers learn from their mistakes? JAMA. 1991;265:2089-2094.
  • Wu AW. Medical error: the second victim. The doctor who makes the mistake needs help too. BMJ. 2000;320:726-728.
  • Young A. Case in health law: limits to peer review privilege. Virtual Mentor. December 2003. Accessed February 19, 2004.
  • Ziv A, Small SD, Wolpe PR. Patient safety and simulation-based medical education. Medical Teacher. 2000;22:489-495.
  • Ziv A, Wolpe PR, Small SD, Glick S. Simulation-based medical education: an ethical imperative. Acad Med. 2003;78:783-8.
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