Medical error

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Medical errors are mistakes that are made in a medical setting. Errors are made by every type of health care worker, and in every hospital and health care facility. In 2001, the U.S. Institute of Medicine estimated that, every year, 44,000–98,000 deaths in the USA were related to medical errors. [1]

When an error occurs, the key question becomes, will it be recognized and corrected? Errors that eventually result in injury are typically compounded by subsequent errors of not recognizing that an error has occurred, and not taking remedial action.

Epidemiology/frequency

Errors may occur among hospitalized patients, ambulatory patients, or patients after discharge from the hospital[2].

The frequency of meaningful medical error is debated.[3]

Classification

Errors can be classified into "no fault," "system-related", and "cognitive".[4]

No fault

Examples including overlooking a disease that in a patient with manifestations so atypical that most doctors would not be expected to recognize the underlying disease.

System-related

Examples of system errors include "problems with policies and procedures, inefficient processes, teamwork, and communication."[4] In medical training, breakdowns in teamwork (including supervision) are a cause.[5]

Unclear prose, whether in institutional instructions[6] or reports[7][8], may contribute to errors.

Weekends

Inadequate provision of medical care for patients admitted on weekends may increase mortality in most[9][10][11] but not all[12] studies. The same may be true for in-hospital cardiac arrest.[13] The problem of weekend care may be especially true in teaching hospitals.[10]

Cognitive

Voytovich has classified cognitive error can be further classified into omission of finding, premature closure, inadequate synthesis, and wrong formulation.[14] Similarly, Graber has classified cognitive error into faulty knowledge, faulty data gathering, and faulty synthesis (usually premature closure).[4] An additional classification has been proposed by Kassirer.[15] In medical trainees, cognitive errors are an important cause or medical error.[5] The many cognitive biases that can lead to cognitive error have been inventoried.[16]

Omission of finding

An example is recording a finding during data collection, but not including the finding on the problem list.[14]

Faulty data gathering

An example of faulty data gathering is and incomplete physical examination or not ordering needed tests.[4]

Premature closure

Premature closure is the most common cognitive error.[4][14]

Wrong formulation

Examples of wrong formulation or flawed reasoning are making a diagnosis that is contradicted by clinical findings.

Inadequate knowledge

Inadequate knowledge can be a factor[17], but is uncommon as an isolated problem in studies of causes of medical errors.[4] However, inadequate knowledge was found to be a more common problem in study of appropriateness of care among patients without identified medical errors.[18] It is unclear how often each of the types of cognitive errors such as an incomplete evaluation, omission of a finding, wrong formulation, are partly due to inadequate knowledge of diseases.

Malpractice

For more information, see: Medical malpractice.

If an error involves negligence and results in damage, as those terms are legally defined, it may be treated as medical malpractice and result in substantial liability. The possibility of legal liability can be a barrier to free discussion and disclosure of medical error, hampering efforts to reduce error. Thus, provisions for confidential reporting of errors can be useful.

Prevention

Lessons from aviation

Plane crashes can be dramatic events, causing considerable loss of life and attracting wide publicity damaging to the reputation of the airlines involved, and weakening passenger confidence in air travel. Accordingly, all plane crashes and related serious incidents ("near misses") are exhaustively investigated in an effort to establish their precise causes. By comparison, most medical errors do not have the same wide impact, thus they seldom receive such intense scrutiny and analysis. [19]

An adapted version of a "pilot's checklist" (designed to ensure that safety procedures are rigorously followed when preparing for take-off and landing) has been tested for usefulness in preparation for performing Cesarean delivery under general anesthesia. [20]

Hospital design

Patients placed in isolation rooms for infection control "experience more preventable adverse events, express greater dissatisfaction with their treatment, and have less documented care."[21]

Personnel factors

Reduction of duty hours

A survey of 200 residents who trained both before and after duty hours reform reported improved quality of life. However, "Residents reported that whereas fatigue-related errors decreased slightly, errors related to reduced continuity of care significantly increased." [22]

Oversight of professional conduct

It is not clear that the oversight of professional conduct prevents errors.

Organizations promoting error reduction

Institute for Healthcare Improvement

The Institute for Healthcare Improvement (IHI) defines medical harm as "unintended physical injury resulting from or contributed to by medical care (including the absence of indicated medical treatment) that requires additional monitoring, treatment or hospitalization, or results in death."

100,000 Lives Campaign

In 2004, the IHI initiated the 100,000 Lives Campaign.[23][24] That campaign, participated in by 3,200 hospitals, is estimated to have reduced deaths of patients in hospitals by 122,000 in 18 months. The campaign focused on six "interventions", three focused on common hospital-acquired (nosocomial infections), which had been identified as likely to reduce medical error:

  1. "Deploy Rapid Response Teams…at the first sign of patient decline". Rapid Response Teams (RRSs) are teams of critical care experts. Use of Rapid Response Teams has increased dramatically in U.S. Hospitals, from near zero in 2003 to 1500 in 2006. [25] The benefit of RRSs, including reduction in cardiopulmonary arrest, has not been established in studies on the effectiveness of RRSs.[26]
  2. "Deliver Reliable, Evidence-Based Care for Acute Myocardial Infarction…to prevent deaths from heart attack."
  3. "Prevent Adverse Drug Events (ADEs)…by implementing medication reconciliation."
  4. "Prevent Central Line Infections…by implementing a series of interdependent, scientifically grounded steps called the "Central Line Bundle"."
  5. "Prevent Surgical Site Infections…by reliably delivering the correct perioperative antibiotics at the proper time." Significant reduction may be achieved by procedures as simple as proper hand washing, use of clippers rather than razors to shave the site of surgery, or prompt administration of antibiotics following surgery.[25][27]
  6. "Prevent Ventilator-Associated Pneumonia…by implementing a series of interdependent, scientifically grounded steps including the 'Ventilator Bundle'."
5 Million Lives Campaign

IHI's second campaign, the 5 Million Lives Campaign, [28] aims to eliminate five million incidents of medical harm during a 24-month period, ending Dec. 9, 2008. The campaign challenges 4,000 hospitals to adopt at least one of twelve interventions: the six original interventions and the following six more: [29] [30]

  1. "Prevent Harm from High-Alert Medications... starting with a focus on anticoagulants, sedatives, narcotics, and insulin."
  2. "Reduce Surgical Complications... by reliably implementing all of the changes in care recommended by SCIP, the Surgical Care Improvement Project (http://www.medqic.org/scip)."
  3. "Prevent Pressure Ulcers... by reliably using science-based guidelines for their prevention."
  4. "Reduce Methicillin-Resistant Staphylococcus aureus (MRSA) infection…by reliably implementing scientifically proven infection control practices."
  5. "Deliver Reliable, Evidence-Based Care for Congestive Heart Failure... to avoid readmissions."
  6. "Get Boards on Board … by defining and spreading the best-known leveraged processes for hospital Boards of Directors, so that they can become far more effective in accelerating organizational progress toward safe care."

Agency for Healthcare Research Quality

The American Agency for Healthcare Research and Quality has established 11 priority areas:[31]

  1. Appropriate use of prophylaxis to prevent venous thromboembolism in patients at risk.
  2. Use of perioperative beta-blockers in appropriate patients to prevent perioperative morbidity and mortality.
  3. Use of maximum sterile barriers while placing central intravenous catheters to prevent infections.
  4. Appropriate use of antibiotic prophylaxis in surgical patients to prevent perioperative infections.
  5. Asking that patients recall and restate what they have been told during the informed consent process.
  6. Continuous aspiration of subglottic secretions (CASS) to prevent ventilator-associated pneumonia.
  7. Use of pressure relieving bedding materials to prevent pressure ulcers.
  8. Use of real-time ultrasound guidance during central line insertion to prevent complications.
  9. Patient self-management for warfarin (CoumadinTM) to achieve appropriate outpatient anticoagulation and prevent complications.
  10. Appropriate provision of nutrition, with a particular emphasis on early enteral nutrition in critically ill and surgical patients.
  11. Use of antibiotic-impregnated central venous catheters to prevent catheter-related infections.

The Patient Advocate

Reduction of medical error can be effected on the patient side as well as on the side of the care giver, but only with vigilance on the part of the patient him or herself, or on the part of the patient's advocate.

The physician's perspective

This section was originally copied from Wikipedia and is licensed under the GNU Free Documentation License.

Case reports review the strongly negative emotional impact of mistakes on the doctors who commit them.[32][33][34][35][36]

Coping mechanisms

Essays[37] and studies[38][39] have described physician coping mechanisms.

Recognizing that mistakes are not isolated events

Some doctors recognize that adverse outcomes from errors usually do not happen because of an isolated errors and actually reflect system problems.[40] There may be several breakdowns in processes to allow one adverse outcome. [41] In addition, errors are more common when other demands compete for a physician's attention.[42][43][44] However, placing too much blame on the system may not be constructive.[40]

Placing the practice of medicine in perspective

Essayists imply that the potential to make mistakes is part of what makes being a physician rewarding and without this potential the the rewards of medical practice would be less:

  • "Everybody dies, you and all of your patients. All relationships end. Would you want it any other way?...Don't take it personally"[45]
  • "... if I left medicine, I would mourn its loss as I've mourned the passage of my poetry. On a daily basis, it is both a privilege and a joy to have the trust of patients and their families and the camaraderie of peers. There is no challenge to make your blood race like that of a difficult case, no mind game as rigorous as the challenging differential diagnosis, and though the stakes are high, so are the rewards."[46]

Disclosing mistakes

Forgiveness, which is a part of many religions, may be important in coping with medical mistakes.[47]

Disclosure to oneself

Inability to forgive oneself may create a cycle of distress and increased likelihood of a future error.[48]

However, "...those who coped by accepting responsibility were more likely to make constructive changes in practice, but to experience more emotional distress."[49] It may be helpful to consider the much larger number of patients who are not exposed to mistakes and are helped by medical care.[46]

Disclosure to patients

Patients are reported to want "information about what happened, why the error happened, how the error's consequences will be mitigated, and how recurrences will be prevented."[50] Detailed suggestions on how to disclose are available.[51]

The American Medical Association's Council on Ethical and Judicial Affairs states in its ethics code:

"Situations occasionally occur in which a patient suffers significant medical complications that may have resulted from the physician's mistake or judgment. In these situations, the physician is ethically required to inform the patient of all facts necessary to ensure understanding of what has occurred. Concern regarding legal liability which might result following truthful disclosure should not affect the physician's honesty with a patient."

From the American College of Physicians Ethics Manual[52]:

“In addition, physicians should disclose to patients information about procedural or judgment errors made in the course of care if such information is material to the patient's well-being. Errors do not necessarily constitute improper, negligent, or unethical behavior, but failure to disclose them may.”

However, "there appears to be a gap between physicians' attitudes and practices regarding error disclosure. Willingness to disclose errors was associated with higher training level and a variety of patient-centered attitudes, and it was not lessened by previous exposure to malpractice litigation".[53] Hospital administrators may share these concerns.[54]

Consequently, in the United States, many states have enacted laws excluding expressions of sympathy after accidents as proof of liability; however, "excluding from admissibility in court proceedings apologetic expressions of sympathy but not fault-admitting apologies after accidents"[55]

Disclosure may actually reduce malpractice payments.[56][57]

Disclosure to non-physicians

In a study of physicians who reported having made a mistake, disclosing to non-physicians sources of support may reduce stress more than disclosing to physician colleagues[39]. This may be due to the physicians in the same study, when presented with a hypothetical scenario of a mistake made by another colleague, only 32% physicians would have unconditionally offered support. It is possible that greater benefit occurs when spouses are physicians[58].

Disclosure to other physicians

Discussing mistakes with other doctors is beneficial.[40] However, doctors may be less forgiving of each other.[58] The reason is not clear, but one essayist has admonished, "Don't Take Too Much Joy in the Mistakes of Other Doctors."[59]

Disclosure to the physician's institution

Disclosure of errors, especially 'near misses' may be able to reduce subsequent errors in institutions that are capable of reviewing near misses.[60] However, doctors report that institutions may not be supportive of the doctor.[40]

References

  1. ↑ Page 1, To Err Is Human: Building a Safer Health System, Janet Corrigan, Molla S. Donaldson, and Linda T. Kohn, editors, National Academy Press (April, 2000), 287 pages, ISBN 0309-06837-1
  2. ↑ Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW (2003). "The incidence and severity of adverse events affecting patients after discharge from the hospital". Ann. Intern. Med. 138 (3): 161–7. PMID 12558354. [e]
  3. ↑ Hayward RA, Hofer TP (2001). "Estimating hospital deaths due to medical errors: preventability is in the eye of the reviewer". JAMA 286 (4): 415–20. PMID 11466119. [e]
  4. ↑ 4.0 4.1 4.2 4.3 4.4 4.5 Graber ML, Franklin N, Gordon R (2005). "Diagnostic error in internal medicine". Arch. Intern. Med. 165 (13): 1493–9. DOI:10.1001/archinte.165.13.1493. PMID 16009864. Research Blogging.
  5. ↑ 5.0 5.1 Singh H, Thomas EJ, Petersen LA, Studdert DM (2007). "Medical errors involving trainees: a study of closed malpractice claims from 5 insurers". Arch. Intern. Med. 167 (19): 2030–6. DOI:10.1001/archinte.167.19.2030. PMID 17954795. Research Blogging.
  6. ↑ Wheeler DW, Carter JJ, Murray LJ, et al (2008). "The effect of drug concentration expression on epinephrine dosing errors: a randomized trial". Ann. Intern. Med. 148 (1): 11–4. PMID 18166759. [e]
  7. ↑ Bundens WP, Bergan JJ, Halasz NA, Murray J, Drehobl M (1995). "The superficial femoral vein. A potentially lethal misnomer". JAMA 274 (16): 1296–8. PMID 7563535. [e]
  8. ↑ Pritchard J, Foley P, Wong H (2003). "Langerhans and Langhans: what's misleading in a name?". Lancet 362 (9387): 922. DOI:1016/S0140-6736(03)14323-1. PMID 13678997. Research Blogging.
  9. ↑ Kostis WJ, Demissie K, Marcella SW, Shao YH, Wilson AC, Moreyra AE (2007). "Weekend versus weekday admission and mortality from myocardial infarction". N. Engl. J. Med. 356 (11): 1099–109. DOI:10.1056/NEJMoa063355. PMID 17360988. Research Blogging.
  10. ↑ 10.0 10.1 Cram P, Hillis SL, Barnett M, Rosenthal GE (2004). "Effects of weekend admission and hospital teaching status on in-hospital mortality". Am. J. Med. 117 (3): 151–7. DOI:10.1016/j.amjmed.2004.02.035. PMID 15276592. Research Blogging.
  11. ↑ Bell CM, Redelmeier DA (2001). "Mortality among patients admitted to hospitals on weekends as compared with weekdays". N. Engl. J. Med. 345 (9): 663–8. PMID 11547721. [e]
  12. ↑ Gould JB, Qin C, Marks AR, Chavez G (2003). "Neonatal mortality in weekend vs weekday births". JAMA 289 (22): 2958–62. DOI:10.1001/jama.289.22.2958. PMID 12799403. Research Blogging.
  13. ↑ Peberdy MA, Ornato JP, Larkin GL, et al (2008). "Survival from in-hospital cardiac arrest during nights and weekends". JAMA 299 (7): 785-92. DOI:10.1001/jama.299.7.785. PMID 18285590. Research Blogging.
  14. ↑ 14.0 14.1 14.2 Dubeau CE, Voytovich AE, Rippey RM (1986). "Premature conclusions in the diagnosis of iron-deficiency anemia: cause and effect". Medical decision making : an international journal of the Society for Medical Decision Making 6 (3): 169–73. PMID 3736379. [e]
  15. ↑ Kassirer JP, Kopelman RI (1989). "Cognitive errors in diagnosis: instantiation, classification, and consequences". Am. J. Med. 86 (4): 433–41. PMID 2648823. [e]
  16. ↑ Croskerry P (2002). "Achieving quality in clinical decision making: cognitive strategies and detection of bias". Academic emergency medicine : official journal of the Society for Academic Emergency Medicine 9 (11): 1184–204. PMID 12414468. [e]
  17. ↑ Graber M, Gordon R, Franklin N (2002). "Reducing diagnostic errors in medicine: what's the goal?". Academic medicine : journal of the Association of American Medical Colleges 77 (10): 981–92. PMID 12377672. [e]
  18. ↑ Lucas BP, Evans AT, Reilly BM, et al (2004). "The impact of evidence on physicians' inpatient treatment decisions". Journal of general internal medicine : official journal of the Society for Research and Education in Primary Care Internal Medicine 19 (5 Pt 1): 402–9. DOI:10.1111/j.1525-1497.2004.30306.x. PMID 15109337. Research Blogging.
  19. ↑ Robert L Helmreich RL (2000) On error management: lessons from aviation. BMJ320:781-5
  20. ↑ Hart EM, Owen H (2005) Errors and omissions in anesthesia: a pilot study using a pilot's checklist. Anesthesia & Analgesia 101:246-50 PMID 15976240
  21. ↑ Stelfox HT, Bates DW, Redelmeier DA (2003). "Safety of patients isolated for infection control". JAMA 290 (14): 1899–905. DOI:10.1001/jama.290.14.1899. PMID 14532319. Research Blogging.
  22. ↑ Myers JS et al. (2006)Internal medicine and general surgery residents' attitudes about the ACGME duty hours regulations: a multicenter study, Academic Medicine 81:1052-8, PMID 17122468
  23. ↑ Berwick DM, Calkins DR, McCannon CJ, Hackbarth AD (2006). "The 100,000 lives campaign: setting a goal and a deadline for improving health care quality". JAMA 295 (3): 324–7. DOI:10.1001/jama.295.3.324. PMID 16418469. Research Blogging.
  24. ↑ Institute for Healthcare Improvement: Overview of the 100,000 Lives Campaign. Retrieved on 2008-01-03.
  25. ↑ 25.0 25.1 “Status Quon’t”, IHI’s 2007 Progress Report (PDF file)
  26. ↑ Ranji SR, Auerbach AD, Hurd CJ, O'Rourke K, Shojania KG (2007). "Effects of rapid response systems on clinical outcomes: systematic review and meta-analysis". J Hosp Med 2 (6): 422–32. DOI:10.1002/jhm.238. PMID 18081187. Research Blogging.
  27. ↑ "Nosocomial Infection: Approach to Postoperative Symptoms of Infection", From ACS Surgery Online, Posted 06/07/2006, E. Patchen Dellinger, M.D., F.A.C.S.
  28. ↑ Institute for Healthcare Improvement: Campaign. Retrieved on 2008-01-03.
  29. ↑ "Overview of the 5 Million Lives Campaign"
  30. ↑ "IHI Launches National Initiative to Reduce Medical Harm in U.S. Hospitals, Builds on 100,000 Lives Campaign" Infection Control Today, December 12, 2006
  31. ↑ Clear Opportunities for Safety Improvement. Agency for Healthcare Research Quality (2001). Retrieved on 2008-02-12.
  32. ↑ Hilfiker D (1984). "Facing our mistakes". N. Engl. J. Med. 310 (2): 118-22. PMID 6690918. [e]
  33. ↑ Christensen JF, Levinson W, Dunn PM (1992). "The heart of darkness: the impact of perceived mistakes on physicians". Journal of general internal medicine : official journal of the Society for Research and Education in Primary Care Internal Medicine 7 (4): 424-31. PMID 1506949. [e]
  34. ↑ Wu AW (2000). "Medical error: the second victim. The doctor who makes the mistake needs help too". BMJ 320 (7237): 726-7. PMID 10720336. [e]
  35. ↑ Waterman AD, Garbutt J, Hazel E, Dunagan WC, Levinson W, Fraser VJ, Gallagher TH. (2007). "The Emotional Impact of Medical Errors on Practicing Physicians in the United States and Canada". Joint Commission Journal on Quality and Patient Safety 33: 467-476. PMID 6690918. [e]
  36. ↑ Delbanco T, Bell SK (2007). "Guilty, afraid, and alone--struggling with medical error". N. Engl. J. Med. 357 (17): 1682–3. DOI:10.1056/NEJMp078104. PMID 17960011. Research Blogging.
  37. ↑ Oscar London (1987). “Rule 13: When You Make a Mistake So Horrible It is to Die Over, Don't”, Kill as few patients as possible: and fifty-six other essays on how to be the world's best doctor. Berkeley, Calif: Ten Speed Press, 23-24. ISBN 0-89815-197-X. 
  38. ↑ Quill TE, Williamson PR. Healthy approaches to physician stress. Arch Intern Med. 1990;150:1857-61. PMID 2393317
  39. ↑ 39.0 39.1 Newman MC (1996). "The emotional impact of mistakes on family physicians". Archives of family medicine 5 (2): 71-5. PMID 8601210. [e]
  40. ↑ 40.0 40.1 40.2 40.3 Wu AW, Folkman S, McPhee SJ, Lo B (1991). "Do house officers learn from their mistakes?". JAMA 265 (16): 2089-94. PMID 2013929. [e]
  41. ↑ Gandhi TK, Kachalia A, Thomas EJ, et al (2006). "Missed and delayed diagnoses in the ambulatory setting: a study of closed malpractice claims". Ann. Intern. Med. 145 (7): 488-96. PMID 17015866. [e]
  42. ↑ Redelmeier DA, Tan SH, Booth GL (1998). "The treatment of unrelated disorders in patients with chronic medical diseases". N. Engl. J. Med. 338 (21): 1516-20. PMID 9593791. [e]
  43. ↑ Lurie N, Rank B, Parenti C, Woolley T, Snoke W (1989). "How do house officers spend their nights? A time study of internal medicine house staff on call". N. Engl. J. Med. 320 (25): 1673-7. PMID 2725617. [e]
  44. ↑ Lyle CB, Applegate WB, Citron DS, Williams OD (1976). "Practice habits in a group of eight internists". Ann. Intern. Med. 84 (5): 594-601. PMID 1275366. [e]
  45. ↑ Thomas Laurence, (2004). “What Do You Want?”, Extreme Clinic -- An Outpatient Doctor's Guide to the Perfect 7 Minute Visit. Philadelphia: Hanley & Belfus, 120. ISBN 1-56053-603-9. 
  46. ↑ 46.0 46.1 Seder D (2006). "Of poems and patients". Ann. Intern. Med. 144 (2): 142. PMID 16418416. [e]
  47. ↑ Berlinger N, Wu A (2005). "Subtracting insult from injury: addressing cultural expectations in the disclosure of medical error". J Med Ethics 31 (2): 106-8. PMID 15681676.
  48. ↑ West CP, Huschka MM, Novotny PJ, et al (2006). "Association of perceived medical errors with resident distress and empathy: a prospective longitudinal study". JAMA 296 (9): 1071-8. DOI:10.1001/jama.296.9.1071. PMID 16954486. Research Blogging.
  49. ↑ Wu AW, Folkman S, McPhee SJ, Lo B (1993). "How house officers cope with their mistakes". West. J. Med. 159 (5): 565-9. PMID 8279153. [e]
  50. ↑ Gallagher TH, Waterman AD, Ebers AG, Fraser VJ, Levinson W (2003). "Patients' and physicians' attitudes regarding the disclosure of medical errors". JAMA 289 (8): 1001-7. PMID 12597752. [e]
  51. ↑ Wu AW, Cavanaugh TA, McPhee SJ, Lo B, Micco GP (1997). "To tell the truth: ethical and practical issues in disclosing medical mistakes to patients". Journal of general internal medicine : official journal of the Society for Research and Education in Primary Care Internal Medicine 12 (12): 770-5. DOI:10.1046/j.1525-1497.1997.07163.x. PMID 9436897. Research Blogging.
  52. ↑ Snyder L, Leffler C (2005). "Ethics manual: fifth edition". Ann Intern Med 142 (7): 560-82. PMID 15809467.
  53. ↑ Kaldjian LC, Jones EW, Wu BJ, Forman-Hoffman VL, Levi BH, Rosenthal GE (2007). "Disclosing medical errors to patients: attitudes and practices of physicians and trainees". Journal of general internal medicine : official journal of the Society for Research and Education in Primary Care Internal Medicine 22 (7): 988-96. DOI:10.1007/s11606-007-0227-z. PMID 17473944. Research Blogging.
  54. ↑ Weissman JS, Annas CL, Epstein AM, et al (2005). "Error reporting and disclosure systems: views from hospital leaders". JAMA 293 (11): 1359-66. DOI:10.1001/jama.293.11.1359. PMID 15769969. Research Blogging.
  55. ↑ SorryWorks.net. Retrieved on 2007-08-16.
  56. ↑ Wu AW (1999). "Handling hospital errors: is disclosure the best defense?". Ann. Intern. Med. 131 (12): 970-2. PMID 10610651. [e]
  57. ↑ Zimmerman R. Doctors' New Tool To Fight Lawsuits: Saying 'I'm Sorry', Dow Jones & Company, Inc, May 18,2004. Retrieved on 2007-08-16.
  58. ↑ 58.0 58.1 Sobecks NW, Justice AC, Hinze S, et al (1999). "When doctors marry doctors: a survey exploring the professional and family lives of young physicians". Ann. Intern. Med. 130 (4 Pt 1): 312-9. PMID 10068390. [e]
  59. ↑ Oscar London (1987). “Rule 35: Don't Take Too Much Joy in the Mistakes of Other Doctors”, Kill as few patients as possible: and fifty-six other essays on how to be the world's best doctor. Berkeley, Calif: Ten Speed Press. ISBN 0-89815-197-X. 
  60. ↑ Barach P, Small SD (2000). "Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems". BMJ 320 (7237): 759-63. PMID 10720361. [e]

See also

External links

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