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Review

An Overview of To Err is Human: Re-emphasizing the Message of Patient Safety

In: Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 3.
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Review

An Overview of To Err is Human: Re-emphasizing the Message of Patient Safety

Molla Sloane Donaldson.
Free Books & Documents

Excerpt

Now, 7 years after the release of To Err is Human, extensive efforts have been reported in journals, technical reports, and safety-oriented conferences. That literature described the magnitude of problems in a variety of care settings, the efforts to make change, and the results of those efforts in improving patient safety. Many of those studies are referenced and discussed throughout this book. Other authors have written incisively about what progress has and has not been made in the past 7 years and the challenges in creating cultures of safety., The greatest challenge we all face is to learn, use, and share better information about how to prevent harm to patients.

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References

    1. Kohn LT, Corrigan JM, Donaldson MS, editors. To err is human: building a safer health system . Washington, DC: National Academy Press, Institute of Medicine; 1999. - PubMed
    1. News Release: Medical Errors Report for Immediate Release, Nov. 29, 1999, National Academy of Sciences. “Preventing Death and Injury from Medical Errors Requires Dramatic, System-Wide Changes.”

    1. Reason JT. Human Error . New York, NY: Cambridge University Press; 1990.
    1. Safe Practices for Better Health Care. Rockville, MD: Agency for Healthcare Research and Quality; Mar, 2005. Fact Sheet AHRQ Publication No 04-P025. Executive Summary of the National Quality Forum’s report, Safe Practices for Better Healthcare: A Consensus Report is available at www.ahrq.gov/qual/nqfpract.htm.
    1. The Joint Commission on Accreditation of Healthcare Organizations. Sentinel Event. [accessed October 31, 2006]. http://www.jointcommission.org/SentinelEvents/

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