R Amalberti, Y Auroy, D Berwick, P … - Annals of Internal …, 2005 - Am Coll Physicians Although debate continues over estimates of the amount of preventable medical harm that occurs in
health care, there seems to be a consensus that health care is not as safe and reliable as it might
be. It is often assumed that ... Cited by 168 - Related articles - All 19 versions
Y Auroy, D Benhamou, R Amaberti - Anesthesiology, 2004 - journals.lww.com ALTHOUGH one may be tempted to neglect rare com- plications because they are infrequent and
therefore difficult to study, they require our attention for several reasons. They are often severe.
They are often thought by our ... Cited by 22 - Related articles - BL Direct - All 3 versions
LL Leape, DM Berwick - Jama, 2005 - Am Med Assoc Five years ago, the Institute of Medicine (IOM) called for a national effort to make health care
safe. Although progress since then has been slow, the IOM report truly "changed the conversation" to
a focus on changing systems, ... Cited by 495 - Related articles - All 5 versions
ET Baer - Anesthesiology, 2006 - journals.lww.com A fatal case of viridans streptococcus meningitis is reported, which occurred as a complication of
epidural anesthesia. One hundred seventy-nine reported cases of post–dural puncture meningitis are
reviewed. Evidence suggests that ... Cited by 41 - Related articles - All 4 versions
- ►ajronline.org [PDF] RS Seigel, AG Williams, RE … - American Journal of …, 1982 - Am Roentgen Ray Soc Aseptic technique is essential in the performance of myelography. However, ... Arlington, Tex.)
from surgical gloves and other particulate contaminants within ... Materials and Methods The tip of
a myelographic needle stylet was ... Cited by 10 - Related articles - All 2 versions
JS Carroll, JW Rudolph - Quality and Safety in Health Care, 2006 - qshc.bmj.com To improve safety performance, many healthcare organizations have sought to emulate high reliability
organizations from industries such as nuclear power, chemical processing, and military operations.We
outline high reliability design ... Cited by 11 - Related articles - BL Direct - All 4 versions
- ►ttl.fi [PDF] E Hollnagel, DD Woods, N Leveson - 2006 - books.google.com Resilience Engineering Concepts and Precepts Edited by ERlK HOLLNAGEL, DAVID D. WOODS AND NANCY
LEVESON ln resilience engineering, failure is the flip-side of the adaptations necessary to cope
with the complexity of the real ... Cited by 237 - Related articles - BL Direct - All 5 versions
- ►liu.se [PDF] R Amalberti - Safety Science, 2001 - Elsevier Safety remains driven by a simple principle: complete elimination of technical breakdowns and human
errors. This article tries to put this common sense approach back into perspective in the case of
ultra-safe systems, where the ... Cited by 142 - Related articles - All 4 versions
- ►shouxi.net TA Brennan, A Gawande, E Thomas, D … - The New England journal …, 2005 - nejm.highwire.org Hence, the answer to the question being asked five years later — how many deaths have been
prevented? — is disappointing. But so is the question. The problem lies in an overreliance on the
notion of the individual accidental ... Cited by 87 - Related articles - BL Direct - All 13 versions
JT Reason, J Carthey, MR De Leval - Quality in Health Care, 2001 - qshc.bmj.com Investigations of accidents in a number of hazardous domains suggest that a cluster of
organisational pathologies—the “vulnerable system syndrome” (VSS)—render some systems more
liable to adverse events. This ... Cited by 92 - Related articles - BL Direct - All 13 versions
