||The examples and perspective in this article deal primarily with the United States and do not represent a worldwide view of the subject. (December 2010)|
A medical error is a preventable adverse effect of care, whether or not it is evident or harmful to the patient. This might include an inaccurate or incomplete diagnosis or treatment of a disease, injury, syndrome, behavior, infection, or other ailment. Globally it is estimated that 142,000 people died in 2013 from adverse effects of medical treatment up from 94,000 in 1990.
- 1 Definitions
- 2 Impact
- 3 Causes
- 4 After an error has occurred
- 4.1 Recognizing that mistakes are not isolated events
- 4.2 Placing the practice of medicine in perspective
- 4.3 Disclosing mistakes
- 4.4 Cause-specific preventive measures
- 4.5 In specific specialties
- 4.6 Legal procedure
- 5 Prevention
- 6 Misconceptions
- 7 See also
- 8 References
- 9 Further reading
- 10 External links
The word error in medicine is used as a label for nearly all of the problems harming patients. Medical errors are often described as human errors in healthcare. Whether the label is medical error or human error, one definition used for it in medicine says that it occurs when a health-care provider chooses an inappropriate method of care or improperly executes an appropriate method of care. The definition should be the subject of more debate. For instance, studies of hand hygiene compliance of physicians in an ICU show that compliance varied from 19% to 85%. The deaths that result from infections caught as a result of treatment providers improperly executing an appropriate method of care by not complying with known safety standards for hand hygiene are difficult to regard innocent accidents or mistakes. At the least they are negligence if not dereliction, but in medicine they are lumped together under the word error with innocent accidents and treated as such.
There are many taxonomies for classifying medical errors.
Globally it is estimated that 142,000 people died in 2013 from adverse effects of medical treatment up from 94,000 in 1990.
A 2000 Institute of Medicine report estimated that medical errors result between 44,000 and 98,000 preventable deaths and 1,000,000 excess injuries each year in U.S. hospitals. In the UK, a 2000 study found that an estimated 850,000 medical errors occur each year, costing over £2 billion.
Some researchers questioned the accuracy of the IOM study, criticizing the statistical handling of measurement errors in the report, significant subjectivity in determining which deaths were "avoidable" or due to medical error, and an erroneous assumption that 100% of patients would have survived if optimal care had been provided. A 2001 study in the Journal of the American Medical Association of seven Department of Veterans Affairs medical centers estimated that for roughly every 10,000 patients admitted to the subject hospitals, one patient died who would have lived for three months or more in good cognitive health had "optimal" care been provided.
A 2006 follow-up to the IOM study found that medication errors are among the most common medical mistakes, harming at least 1.5 million people every year. According to the study, 400,000 preventable drug-related injuries occur each year in hospitals, 800,000 in long-term care settings, and roughly 530,000 among Medicare recipients in outpatient clinics. The report stated that these are likely to be conservative estimates. In 2000 alone, the extra medical costs incurred by preventable drug related injuries approximated $887 million—and the study looked only at injuries sustained by Medicare recipients, a subset of clinic visitors. None of these figures take into account lost wages and productivity or other costs.
According to a 2002 Agency for Healthcare Research and Quality report, about 7,000 people were estimated to die each year from medication errors - about 16 percent more deaths than the number attributable to work-related injuries (6,000 deaths). Medical errors affect one in 10 patients worldwide. One extrapolation suggests that 180,000 people die each year partly as a result of iatrogenic injury. One in five Americans (22%) report that they or a family member have experienced a medical error of some kind.
Difficulties in measuring frequency of errors
About 1% of hospital admissions result in an adverse event due to negligence. However, mistakes are likely much more common, as these studies identify only mistakes that led to measurable adverse events occurring soon after the errors. Independent review of doctors' treatment plans suggests that decision-making could be improved in 14% of admissions; many of the benefits would have delayed manifestations. Even this number may be an underestimate. One study suggests that, in the United States, adults receive only 55% of recommended care. At the same time, a second study found that 30% of care in the United States may be unnecessary. For example, if a doctor fails to order a mammogram that is past due, this mistake will not show up in the first type of study. And because no adverse event occurred during the short follow-up of the study, the mistake also would not show up in the second type of study, because only the principal treatment plans were critiqued. However, the mistake would be recorded in the third type of study. If a doctor recommends an unnecessary treatment or test, it may not show in any of these types of studies.
Medical errors are associated with inexperienced physicians and nurses, new procedures, extremes of age, and complex or urgent care. Poor communication (whether in one's own language or, as may be the case for medical tourists, another language), improper documentation, illegible handwriting, inadequate nurse-to-patient ratios, and similarly named medications are also known to contribute to the problem. Patient actions may also contribute significantly to medical errors. Falls, for example, may result from patients' own misjudgements. Human error has been implicated in nearly 80 percent of adverse events that occur in complex healthcare systems. The vast majority of medical errors result from faulty systems and poorly designed processes versus poor practices or incompetent practitioners.
Complicated technologies, powerful drugs, intensive care, and prolonged hospital stay can contribute to medical errors.
System and process design
In 2000, The Institute of Medicine released "To Err is Human," which asserts that the problem in medical errors is not bad people in health care—it is that good people are working in bad systems that need to be made safer.
Poor communication and unclear lines of authority of physicians, nurses, and other care providers are also contributing factors. Disconnected reporting systems within a hospital can result in fragmented systems in which numerous hand-offs of patients results in lack of coordination and errors.
Other factors include the impression that action is being taken by other groups within the institution, reliance on automated systems to prevent error., and inadequate systems to share information about errors, which hampers analysis of contributory causes and improvement strategies. Cost-cutting measures by hospitals in response to reimbursement cutbacks can compromise patient safety. In emergencies, patient care may be rendered in areas poorly suited for safe monitoring. The American Institute of Architects has identified concerns for the safe design and construction of health care facilities. Infrastructure failure is also a concern. According to the WHO, 50% of medical equipment in developing countries is only partly usable due to lack of skilled operators or parts. As a result, diagnostic procedures or treatments cannot be performed, leading to substandard treatment.
The Joint Commission's Annual Report on Quality and Safety 2007 found that inadequate communication between healthcare providers, or between providers and the patient and family members, was the root cause of over half the serious adverse events in accredited hospitals. Other leading causes included inadequate assessment of the patient's condition, and poor leadership or training.
Competency, education, and training
Variations in healthcare provider training & experience and failure to acknowledge the prevalence and seriousness of medical errors also increase the risk. The so-called July effect occurs when new residents arrive at teaching hospitals, causing an increase in medication errors according to a study of data from 1979-2006.
Human factors and ergonomics
Cognitive errors commonly encountered in medicine were initially identified by psychologists Amos Tversky and Daniel Kahneman in the early 1970s. Jerome Groopman, author of How Doctors Think, says these are "cognitive pitfalls", biases which cloud our logic. For example, a practitioner may overvalue the first data encountered, skewing his thinking. Or recent or dramatic cases which come quickly to mind and may color judgement. Another pitfall is where stereotypes may prejudice thinking.
Sleep deprivation has also been cited as a contributing factor in medical errors. One study found that being awake for over 24 hours caused medical interns to double or triple the number of preventable medical errors, including those that resulted in injury or death. The risk of car crash after these shifts increased by 168%, and the risk of near miss by 460%. Interns admitted falling asleep during lectures, during rounds, and even during surgeries. Night shifts are associated with worse surgeon performance during laparoscopic surgeries.
Practitioner risk factors include fatigue and depression and burnout. Factors related to the clinical setting include diverse patients, unfamiliar settings, time pressures, and increased patient to nurse staffing ratio increases. Drug names that look alike or sound alike are also a problem.
Errors can include misdiagnosis or delayed diagnosis, administration of the wrong drug to the wrong patient or in the wrong way, giving multiple drugs that interact negatively, surgery on an incorrect site, failure to remove all surgical instruments, failure to take the correct blood type into account, or incorrect record-keeping.
Errors in diagnosis
A large study reported several cases where patients were wrongly told that they were HIV-negative when the physicians erroneously ordered and interpreted HTLV (a closely related virus) testing rather than HIV testing. In the same study, >90% of HTLV tests were ordered erroneously. It is estimated that between 10-15 percent of physician diagnoses are erroneous.
Misdiagnosis of psychological disorders
Regarding mental illnesses, sufferers of dissociative identity disorder usually have psychiatric histories that contain three or more separate mental disorders and previous treatment failures. The disbelief of some doctors around the validity of dissociative identity disorder may also add to its misdiagnosis.
Studies have found that bipolar disorder has often been misdiagnosed as major depression. Its early diagnosis necessitates that clinicians pay attention to the features of the patient's depression and also look for present or prior hypomanic or manic symptomatology.
The DSM-5 field trials included "test-retest reliability" which involved different clinicians doing independent evaluations of the same patient—a new approach to the study of diagnostic reliability.
Most common misdiagnoses
A 2009 meta-analysis identified the 5 most commonly mis-diagnosed diseases as: infection, neoplasm, myocardial infarction, pulmonary emboli, and cardiovascular disease. Physician familiarity with this information is variable.
Outpatient vs. inpatient
Misdiagnosis is the leading cause of medical error in outpatient facilities. Since the National Institute of Medicine’s 1999 report, “To Err is Human,” found up to 98,000 hospital patients die from preventable medical errors in the U.S. each year, government and private sector efforts have focused on inpatient safety.
After an error has occurred
Recognizing that mistakes are not isolated events
Some physicians recognize that adverse outcomes from errors usually do not happen because of an isolated errors and actually reflect system problems. This concept is often referred to as the Swiss Cheese Model. This is the concept that there are layers of protection for clinicians and patient to prevent mistakes from occurring. Therefore, even if a doctor or nurse makes a small error (incorrect dose of drug written on a drug chart by doctor) this is picked up before it actually affects patient care (pharmacist checks the drug chart and makes rectifies the error). Such mechanisms include: Practical alterations (e.g.-medications that cannot be given IV, are fitted with tubing which means they cannot be linked to an IV even if a clinician makes a mistake and tries to), systematic safety processes (e.g.- all patients must have a Waterlow score assessment and falls assessment completed on admission), training programmes/continuing professional development courses  are measures that may be put in place.
There may be several breakdowns in processes to allow one adverse outcome. In addition, errors are more common when other demands compete for a physician's attention. However, placing too much blame on the system may not be constructive.
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 rewards of medical practice would be less. Laurence states that "Everybody dies, you and all of your patients. All relationships end. Would you want it any other way? [...] Don't take it personally" Seder states "[...] 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."
Disclosure to oneself
Inability to forgive oneself may create a cycle of distress and increased likelihood of a future error.
However, Wu et al. suggest "...those who coped by accepting responsibility were more likely to make constructive changes in practice, but [also] to experience more emotional distress." It may be helpful to consider the much larger number of patients who are not exposed to mistakes and are helped by medical care.
Disclosure to patients
Gallagher et al. state that patients want "information about what happened, why the error happened, how the error's consequences will be mitigated, and how recurrences will be prevented." Interviews with patients and families reported in a 2003 book by Rosemary Gibson and Janardan Prasad Singh, that those who have been harmed by medical errors face a "wall of silence" and "want an acknowledgement" of the harm. With honesty, "healing can begin not just for the patients and their families but also the doctors, nurses and others involved." Detailed suggestions on how to disclose are available.
A 2005 study by Wendy Levinson of the University of Toronto showed surgeons discussing medical errors used the word "error" or "mistake" in only 57 per cent of disclosure conversations and offered a verbal apology only 47 per cent of the time.
Patient disclosure is important in the medical error process. The current standard of practice at many hospitals is to disclose errors to patients when they occur. In the past, it was a common fear that disclosure to the patient would incite a malpractice lawsuit. Many physicians would not explain that an error had taken place, causing a lack of trust toward the healthcare community. In 2007, 34 states passed legislation that precludes any information from a physician’s apology for a medical error from being used in malpractice court (even a full admission of fault). This encourages physicians to acknowledge and explain mistakes to patients, and keeping an open line of communication.
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:
- “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". Hospital administrators may share these concerns.
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"
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. 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.
Disclosure to other physicians
Discussing mistakes with other physicians is beneficial. However, medical providers may be less forgiving of each other. The reason is not clear, but one essayist has admonished, "Don't Take Too Much Joy in the Mistakes of Other Doctors."
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. However, doctors report that institutions may not be supportive of the doctor.
Use of rationalization to cover up medical errors
By presence of to the patient
A survey of more than 10,000 physicians in the United States came to the results that, on the question "Are there times when it's acceptable to cover up or avoid revealing a mistake if that mistake would not cause harm to the patient?", 19% answered yes, 60% answered no and 21% answered it depends. On the question "Are there times when it is acceptable to cover up or avoid revealing a mistake if that mistake would potentially or likely harm the patient?", 2% answered yes, 95% answered no and 3% answered it depends.
Cause-specific preventive measures
Traditionally, errors are attributed to mistakes made by individuals who may be penalized for these mistakes. The usual approach to correct the errors is to create new rules with additional checking steps in the system, aiming to prevent further errors. As an example, an error of free flow IV administration of heparin is approached by teaching staff how to use the IV systems and to use special care in setting the IV pump. While overall errors become less likely, the checks add to workload and may in themselves be a cause of additional errors.
A newer model for improvement in medical care takes its origin from the work of W. Edwards Deming in a model of Total Quality Management. In this model, there is an attempt to identify the underlying system defect that allowed the opportunity for the error to occur. As an example, in such a system the error of free flow IV administration of Heparin is dealt with by not using IV heparin and substituting subcutaneous administration of heparin, obviating the entire problem. However, such an approach presupposes available research showing that subcutaneous heparin is as effective as IV. Thus, most systems use a combination of approaches to the problem.
In specific specialties
The field of medicine that has taken the lead in systems approaches to safety is anaesthesiology. Steps such as standardization of IV medications to 1 ml doses, national and international color-coding standards, and development of improved airway support devices has made anesthesia care a model of systems improvement in care.
Pharmacy professionals have extensively studied the causes of errors in the prescribing, preparation, dispensing and administration of medications. As far back as the 1930s, pharmacists worked with physicians to select, from amongst many options, the safest and most effective drugs available for use in hospitals. The process is known as the Formulary System and the list of drugs is known as the Formulary. In the 1960s, hospitals implemented unit dose packaging and unit dose drug distribution systems to reduce the risk of wrong drug and wrong dose errors in hospitalized patients; centralized sterile admixture services were shown to decrease the risks of contaminated and infected intravenous medications; pharmacy computers screened each patient’s medication list for drug-drug interactions; and, pharmacists provided drug information and clinical decision support directly to physicians to improve the safe and effective use of medications. Pharmacists are recognized experts in medication safety and have made many contributions that reduce error and improve patient care over the last 50 years. More recently, governments have attempted to address issues like patient-pharmacists communication and consumer knowledge through measures like the Australian Government's Quality Use of Medicines policy.
Standards and regulations for medical malpractice vary by country and jurisdiction within countries. Medical professionals may obtain professional liability insurances to offset the risk and costs of lawsuits based on medical malpractice.
Medical care is frequently compared adversely to aviation; while many of the factors that lead to errors in both fields are similar, aviation's error management protocols are regarded as much more effective. Safety measures include informed consent, the availability of a second practitioner's opinion, voluntary reporting of errors, root cause analysis, reminders to improve patient medication adherence, hospital accreditation, and systems to ensure review by experienced or specialist practitioners
In the United States reporting medical errors in hospitals is a condition of payment by Medicare. An investigation by the Office of Inspector General, Department of Health and Human Services released January 6, 2012 found that most errors are not reported and even in the case of errors that are reported and investigated changes are seldom made which would prevent them in the future. The investigation revealed that there was often lack of knowledge regarding which events were reportable and recommended that lists of reportable events be developed.
Common misconceptions about adverse events are the following, and in parentheses are the arguments and explanations against those misconceptions:
- "Bad apples" or incompetent health care providers are a common cause. (Although human error is commonly an initiating event, the faulty process of delivering care invariably permits or compounds the harm, and is the focus of improvement.
- High risk procedures or medical specialties are responsible for most avoidable adverse events. (Although some mistakes, such as in surgery, are harder to conceal, errors occur in all levels of care. Even though complex procedures entail more risk, adverse outcomes are not usually due to error, but to the severity of the condition being treated.). However, USP has reported that medication errors during the course of a surgical procedure are three times more likely to cause harm to a patient than those occurring in other types of hospital care.
- If a patient experiences an adverse event during the process of care, an error has occurred. (Most medical care entails some level of risk, and there can be complications or side effects, even unforeseen ones, from the underlying condition or from the treatment itself.
- Serious adverse event
- Adverse drug reaction
- Fatal Care: Survive in the U.S. Health System (book)
- Medical malpractice
- Medical resident work hours
- Patient Safety and Quality Improvement Act of 2005
- Patient safety organization
- Quality Use of Medicines
- To Err is Human: Building a Safer Health System
- GBD 2013 Mortality and Causes of Death, Collaborators (17 December 2014). "Global, regional, and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013.". Lancet 385: 117–71. doi:10.1016/S0140-6736(14)61682-2. PMC 4340604. PMID 25530442.
- Zhang, J.; Patel, V.L.; Johnson, T.R (2008). "Medical error: Is the solution medical or cognitive?". Journal of the American Medical Informatics Association 6 (Supp1): 75–77. doi:10.1197/jamia.M1232.
- Salemi C1, Canola MT, Eck EK (Jan 2002). "Hand washing and physicians: how to get them together". Infect Control Hosp Epidemiol (PubMed, US National Library of Medicine, National Institutes of Health) 23: 32–5. doi:10.1086/501965. PMID 11868890.
- Hofer, Timothy P. (November 2000). "What Is an Error?". Effective Clinical Practice (American College of Physicians).
- Hayward, Rodney A.; Hofer, Timothy P. (July 25, 2001). "Estimating Hospital Deaths Due to Medical Errors: Preventability Is in the Eye of the Reviewer". JAMA: the Journal of the American Medical Association 286 (4): 415–20. doi:10.1001/jama.286.4.415. PMID 11466119.
- Kopec, D.; Tamang, S.; Levy, K.; Eckhardt, R.; Shagas, G. (2006). "The state of the art in the reduction of medical errors". Studies in health technology and informatics 121: 126–37. PMID 17095810.
- Institute of Medicine (2000). "To Err Is Human: Building a Safer Health System (2000)". The National Academies Press. Retrieved 2006-06-20.
- Charatan, Fred (2000). "Clinton acts to reduce medical mistakes". BMJ Publishing Group. doi:10.1136/bmj.320.7235.597. Retrieved 2006-03-17.
- Weingart SN, Wilson RM, Gibberd RW, Harrison B; Wilson; Gibberd; Harrison (March 2000). "Epidemiology of medical error". BMJ 320 (7237): 774–7. doi:10.1136/bmj.320.7237.774. PMC 1117772. PMID 10720365.
- Ker, Katharine; Edwards, Philip James; Felix, Lambert M.; Blackhall, Karen; Roberts, Ian (2010). "Caffeine for the prevention of injuries and errors in shift workers". The Cochrane Database of Systematic Reviews (5): CD008508. doi:10.1002/14651858.CD008508. ISSN 1469-493X. PMC 4160007. PMID 20464765.
- Hayward RA, Heisler M, Adams J, Dudley RA, Hofer TP; Heisler; Adams; Dudley; Hofer (August 2007). "Overestimating outcome rates: statistical estimation when reliability is suboptimal". Health Serv Res 42 (4): 1718–38. doi:10.1111/j.1475-6773.2006.00661.x. PMC 1955272. PMID 17610445.
- Hayward R, Hofer T; Hofer (2001). "Estimating hospital deaths due to medical errors: preventability is in the eye of the reviewer". JAMA 286 (4): 415–20. doi:10.1001/jama.286.4.415. PMID 11466119.
- "Medication Errors Injure 1.5 Million People and Cost Billions of Dollars Annually". The National Academy of Science. 2006. Retrieved 2006.
- Leape LL (1994). "Error in medicine". JAMA 272 (23): 1851–7. doi:10.1001/jama.272.23.1851. PMID 7503827.
- 2002 Annual Report, The Commonwealth Fund
- Brennan T, Leape L, Laird N, Hebert L, Localio A, Lawthers A, Newhouse J, Weiler P, Hiatt H; Leape; Laird; Hebert; Localio; Lawthers; Newhouse; Weiler; Hiatt (1991). "Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I". N Engl J Med 324 (6): 370–6. doi:10.1056/NEJM199102073240604. PMID 1987460.
- Lucas B, Evans A, Reilly B, Khodakov Y, Perumal K, Rohr L, Akamah J, Alausa T, Smith C, Smith J; Evans; Reilly; Khodakov; Perumal; Rohr; Akamah; Alausa; Smith; Smith (2004). "The Impact of Evidence on Physicians' Inpatient Treatment Decisions". J Gen Intern Med 19 (5 Pt 1): 402–9. doi:10.1111/j.1525-1497.2004.30306.x. PMC 1492243. PMID 15109337.
- McGlynn EA, Asch SM, Adams J, Keesey J, Hicks J, DeCristofaro A, Kerr EA (2003). "The quality of health care delivered to adults in the United States". N Engl J Med 348: 2635–45. doi:10.1056/NEJMsa022615. PMID 12826639.
- Fisher ES (October 2003). "Medical Care — Is More Always Better?". New England Journal of Medicine 349 (17): 1665–7. doi:10.1056/NEJMe038149. PMID 14573739.
- Weingart, N. Saul; Wilson, Ross; Gibberd, Robert W.; Harrison, Bernadette (2000). "Epidemiology of medical error". BMJ Publishing Group. Retrieved 2006-03-17.
- Palmieri, P. A.; DeLucia, P. R.; Ott, T. E.; Peterson, L. T.; Green, A. (2008). The anatomy and physiology of error in averse healthcare events. Advances in Health Care Management 7. pp. 33–68. doi:10.1016/S1474-8231(08)07003-1. ISBN 978-1-84663-954-8. ISSN 1474-8231.
- National Academy of Sciences. 2000. To Err is Human. Washington, DC: The National Academies Press. http://www.nap.edu/catalog.php?record_id=9728
- Neale, Graham; Woloshynowych, Maria; Vincent, Charles (July 2001). "Exploring the causes of adverse events in NHS hospital practice". Journal of the Royal Society of Medicine 94 (7): 322–30. PMC 1281594. PMID 11418700.
- Gardner, Amanda (6 March 2007). "Medication Errors During Surgeries Particularly Dangerous". The Washington Post. Retrieved 2007-03-13.
- McDonald, MD, Clement J. (4 April 2006). "Computerization Can Create Safety Hazards: A Bar-Coding Near Miss". Annals of Internal Medicine 144 (7): 510–516. doi:10.7326/0003-4819-144-7-200604040-00010. PMID 16585665. Retrieved 2006-07-31.
- US Agency for Healthcare Research & Quality (2008-01-09). "Physicians Want To Learn from Medical Mistakes but Say Current Error-reporting Systems Are Inadequate". Retrieved 2008-03-23.
- Clement JP; Lindrooth RC; Chukmaitov AS; Chen HF (February 2007). "Does the patient's payer matter in hospital patient safety?: a study of urban hospitals". Med Care 45 (2): 131–8. doi:10.1097/01.mlr.0000244636.54588.2b. PMID 17224775.
- "Incorporating Patient-Safe Design into the Guidelines". The American Institute of Architects Academy Journal (The American Institute of Architects). 2005-10-19.
- The Joint Commission’s Annual Report on Quality and Safety 2007: Improving America’s Hospitals (Accessed 2008-04-09)
- Wu AW, Folkman S, McPhee SJ, Lo B (April 1991). "Do house officers learn from their mistakes?". JAMA 265 (16): 2089–94. doi:10.1001/jama.265.16.2089. PMID 2013929.
- Michael L. Millenson (2003). "The Silence". Health Affairs 22 (2): 103–112. doi:10.1377/hlthaff.22.2.103. PMID 12674412. Retrieved 2008-03-23.
- Henneman, Elizabeth A. (1 October 2007). "Unreported Errors in the Intensive Care Unit, A Case Study of the Way We Work". Critical Care Nurse 27 (5): 27–34. PMID 17901458. Retrieved 2008-03-23.
- Phillips DP; Barker GE (May 2010). "A July Spike in Fatal Medication Errors: A Possible Effect of New Medical Residents". J Gen Intern Med 25 (8): 774–779. doi:10.1007/s11606-010-1356-3. PMC 2896592. PMID 20512532.
- "New residents linked to July medication errors", amednews, June 21, 2010, American Medical Association
- Jerome E. Groopman (5 November 2009). "Diagnosis: What Doctors are Missing". New York Review of Books.
- Barger, L. K.; et al. (2006). "Impact of Extended-Duration Shifts on Medical Errors, Adverse Events, and Attentional Failures". PLoS Med 3 (12): e487. doi:10.1371/journal.pmed.0030487. PMC 1705824. PMID 17194188.
- When Doctors Don't Sleep, Talk of the Nation, National Public Radio, 13 December 2006.
- Nocera A, Khursandi DS; Khursandi (June 1998). "Doctors' working hours: can the medical profession afford to let the courts decide what is reasonable?". Med J Aust 168 (12): 616–8. PMID 9673625.
- Landrigan CP, Rothschild JM, Cronin JW; et al. (2004). "Effect of reducing interns' work hours on serious medical errors in intensive care units". N. Engl. J. Med. 351 (18): 1838–48. doi:10.1056/NEJMoa041406. PMID 15509817.
- Barger LK, Ayas NT, Cade BE; et al. (December 2006). "Impact of Extended-Duration Shifts on Medical Errors, Adverse Events, and Attentional Failures". PLoS Med. 3 (12): e487. doi:10.1371/journal.pmed.0030487. PMC 1705824. PMID 17194188.
- Fahrenkopf AM, Sectish TC, Barger LK; et al. (March 2008). "Rates of medication errors among depressed and burnt out residents: prospective cohort study". BMJ 336 (7642): 488–91. doi:10.1136/bmj.39469.763218.BE. PMC 2258399. PMID 18258931.
- Aiken LH, Clarke SP, Sloane DM, Sochalski J, Silber JH; Clarke; Sloane; Sochalski; Silber (2002). "Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction". JAMA 288 (16): 1987–93. doi:10.1001/jama.288.16.1987. PMID 12387650.
- 8th Annual MEDMARX Report (2008-01-29). "Press Release". U.S. Pharmacopeia. Retrieved 2008-03-23.
- Siemieniuk, Reed; Fonseca, Kevin; Gill, M. John (November 2012). "Using Root Cause Analysis and Form Redesign to Reduce Incorrect Ordering of HIV Tests". Joint Commission Journal on Quality and Patient Safety 38 (11): 506–512. PMID 23173397.
- Berner, E. S.; Graber, M. L. (2008). "Overconfidence as a cause of diagnostic error in medicine". American Journal of Medicine 121: S2–S23. doi:10.1016/j.amjmed.2008.01.001.
- "Dissociative Identity Disorder, doctor's reference". Merck.com. 2005-11-01. Retrieved 2008-03-30.
- Bowden, C.L. (2001). "Strategies to Reduce Misdiagnosis of Bipolar Depression". Psychiatr Serv 52 (1): 51–55. doi:10.1176/appi.ps.52.1.51. PMID 11141528. Retrieved 2008-03-30.
- "Schizophrenia Symptoms". schizophrenia.com. Retrieved 2008-03-30.
- Reliability and Prevalence in the DSM-5 Field Trials, January 12, 2012 http://www.dsm5.org/Documents/Reliability_and_Prevalence_in_DSM-5_Field_Trials_1-12-12.pdf
- McDonald CL, Hernandez MB, Gofman Y, Suchecki S, Schreier W. (2009). "The five most common misdiagnoses: a meta-analysis of autopsy and malpractice data". The Internet Journal of Family Practice 7 (3).
- Hernandez MB, McDonald CL, Gofman Y, Trevil R, Bray N, Hasty R, Wadhwa N, Cabrera J, Hardigan PC. (2010). "Physician Familiarity with the Most Common Misdiagnoses: Implications for Clinical Practice and Continuing Medical Education". The Internet Journal of Medical Education 1 (2).
- Janet, Howard. "Malpractice Lawsuits Shed Light on Ailing Outpatient System". My Advocates. Retrieved 28 June 2011.
- Hilfiker D (1984). "Facing our mistakes". N. Engl. J. Med. 310 (2): 118–22. doi:10.1056/NEJM198401123100211. PMID 6690918.
- Christensen JF, Levinson W, Dunn PM; Levinson; Dunn (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. doi:10.1007/bf02599161. PMID 1506949.
- Wu AW (2000). "Medical error: the second victim : The doctor who makes the mistake needs help too". BMJ 320 (7237): 726–7. doi:10.1136/bmj.320.7237.726. PMC 1117748. PMID 10720336.
- Waterman AD, Garbutt J, Hazel E, Dunagan WC, Levinson W, Fraser VJ, Gallagher TH.; Garbutt; Hazel; Dunagan; Levinson; Fraser; Gallagher (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 (2): 467–476. PMID 17724943.
- Wu AW, Folkman S, McPhee SJ, Lo B; Folkman; McPhee; Lo (1991). "Do house officers learn from their mistakes?". JAMA 265 (16): 2089–94. doi:10.1001/jama.265.16.2089. PMID 2013929.
- Dean B; Barber N & Schachter M (Oct 2000). "What is a prescribing error?". Qual Saf Health Care 9 (4): 232‐237. doi:10.1136/qhc.9.4.232.
- Romero‐Perez, Raquel; Dr Philippa Hildick‐Smith (Sep 2012). "Minimising Prescribing Errors in Paediatrics ‐ Clinical Audit". Scottish Universities Medical Journal EPub (EPub 1:14): 1–9.
- 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. doi:10.7326/0003-4819-145-7-200610030-00006. PMID 17015866.
- Redelmeier DA, Tan SH, Booth GL; Tan; Booth (1998). "The treatment of unrelated disorders in patients with chronic medical diseases". N. Engl. J. Med. 338 (21): 1516–20. doi:10.1056/NEJM199805213382106. PMID 9593791.
- Lurie N, Rank B, Parenti C, Woolley T, Snoke W; Rank; Parenti; Woolley; Snoke (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. doi:10.1056/NEJM198906223202507. PMID 2725617.
- Lyle CB, Applegate WB, Citron DS, Williams OD; Applegate; Citron; Williams (1976). "Practice habits in a group of eight internists". Ann. Intern. Med. 84 (5): 594–601. doi:10.7326/0003-4819-84-5-594. PMID 1275366.
- Thomas Laurence, (2004). "What Do You Want?". Extreme Clinic -- An Outpatient Doctor's Guide to the Perfect 7 Minute Visit. Philadelphia: Hanley & Belfus. p. 120. ISBN 1-56053-603-9.
- Seder D (2006). "Of poems and patients". Ann. Intern. Med. 144 (2): 142. doi:10.7326/0003-4819-144-2-200601170-00014. PMID 16418416.
- Berlinger N, Wu A; Wu (2005). "Subtracting insult from injury: addressing cultural expectations in the disclosure of medical error". J Med Ethics 31 (2): 106–8. doi:10.1136/jme.2003.005538. PMC 1734098. PMID 15681676.
- 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.
- Wu AW, Folkman S, McPhee SJ, Lo B; Folkman; McPhee; Lo (1993). "How house officers cope with their mistakes". West. J. Med. 159 (5): 565–9. PMC 1022346. PMID 8279153.
- Gallagher TH, Waterman AD, Ebers AG, Fraser VJ, Levinson W; Waterman; Ebers; Fraser; Levinson (2003). "Patients' and physicians' attitudes regarding the disclosure of medical errors". JAMA 289 (8): 1001–7. doi:10.1001/jama.289.8.1001. PMID 12597752.
- Rosemary Gibson, Janardan Prasad Singh (2003). Wall of Silence. ISBN 089526112X.
- Wu AW, Cavanaugh TA, McPhee SJ, Lo B, Micco GP; Cavanaugh; McPhee; Lo; Micco (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. PMC 1497204. PMID 9436897.
- Kelly, Karen (2005). "Study explores how physicians communicate mistakes". University of Toronto. Archived from the original on 2006-03-22. Retrieved 2006-03-17.
- Agency for Healthcare Research and Quality (AHRQ) http://psnet.ahrq.gov/primer.aspx?primerID=2
- Snyder L, Leffler C; Leffler; Ethics Human Rights Committee (2005). "Ethics manual: fifth edition". Ann Intern Med 142 (7): 560–82. doi:10.7326/0003-4819-142-7-200504050-00014. PMID 15809467.
- Kaldjian LC, Jones EW, Wu BJ, Forman-Hoffman VL, Levi BH, Rosenthal GE; Jones; Wu; Forman-Hoffman; Levi; Rosenthal (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. PMC 2219725. PMID 17473944.
- 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.
- "SorryWorks.net". Retrieved 2007-08-16.
- Wu AW (1999). "Handling hospital errors: is disclosure the best defense?". Ann. Intern. Med. 131 (12): 970–2. doi:10.7326/0003-4819-131-12-199912210-00012. PMID 10610651.
- Zimmerman R (May 18, 2004). "Doctors' New Tool To Fight Lawsuits: Saying 'I'm Sorry'". The Wall Street Journal. p. A1. Archived from the original on August 23, 2007.
- Newman MC (1996). "The emotional impact of mistakes on family physicians". Archives of family medicine 5 (2): 71–5. doi:10.1001/archfami.5.2.71. PMID 8601210.
- 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. doi:10.7326/0003-4819-130-4-199902160-00017. PMID 10068390.
- 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.
- Barach P, Small SD; Small (2000). "Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems". BMJ 320 (7237): 759–63. doi:10.1136/bmj.320.7237.759. PMC 1117768. PMID 10720361.
- Banja, John, Medical Errors and Medical Narcissism, 2005
- 'Some Worms Are Best Left in the Can' -- Should You Hide Medical Errors? By Gail Garfinkel Weiss. Posted: 01/04/2011
- Gaba, David (2000). "Anaesthesiology as a model for patient safety in health care". BMJ Publishing Group. Retrieved 2006-03-17.
- Pease E (1936). "Minimum standards for a hospital pharmacy". Bull Am Coll Surg 21: 34–35.
- Chapter IV.1 Medication Distribution Systems, Garrison TJ (au) in Handbook of Institutional Pharmacy Practice, Smith MC and Brown TR eds, Williams and Wilkins Co. 1979,
- Chapter IV.3 Developing Intravenous Admixture Systems, Woodward WA and Schwartau N (au) in Handbook of Institutional Pharmacy Practice, Smith MC and Brown TR eds, Williams and Wilkins Co. 1979,
- Chapter 53 The Patient Profile System, Powell MF (au) in Handbook of Institutional Pharmacy Practice, Smith MC and Brown TR eds, Williams and Wilkins Co. 1986,
- Chapter 31 Communicating Drug Information, Evens RP (au) in Handbook of Institutional Pharmacy Practice, Smith MC and Brown TR eds, Williams and Wilkins Co. 1986,
- Helmreich, Robert (2000). "On error management: lessons from aviation". BMJ Publishing Group. Retrieved 2006-03-17.
- Espinosa, James; Thomas Nolan (2000). "Reducing errors made by emergency physicians in interpreting radiographs: longitudinal study". BMJ Publishing Group. Retrieved 2006-03-17.
- "Report Finds Most Errors at Hospitals Go Unreported" article by Robert Pear in The New York Times January 6, 2012
- Summary "Hospital Incident Reporting Systems Do Not Capture Most Patient Harm" Report (OEI-06-09-00091) Office of Inspector General, Department of Health and Human Services, January 6, 2012
- René Amalberti, MD, PhD; Yves Auroy, MD; Don Berwick, MD, MPP; and Paul Barach, MD, MPH (3 May 2005). "Five System Barriers to Achieving Ultrasafe Health Care". Annals of Internal Medicine 142 (9): 756–764. doi:10.7326/0003-4819-142-9-200505030-00012. PMID 15867408. Retrieved 2006-07-12.
- Institute of Medicine (1999). "To Err Is Human: Building a Safer Health System, page 4". The National Academies Press. Retrieved 2006-07-01.
- Gawande, Atul (2002). Complications: A Surgeon's Notes on an Imperfect Science. New York: Metropolitan Books. ISBN 0-8050-6319-6.
- Wachter, Robert; Shojania, Kaveh (2004). Internal Bleeding: The Truth Behind America's Terrifying Edidemic of Medical Mistakes. New York: Rugged Land. ISBN 1-59071-016-9.
- Banja, John (2005). Medical Errors and Medical Narcissism. Boston: Jones and Bartlett. ISBN 0-7637-8361-7.
- Porter, Michael E.; Olmsted Teisberg, Elizabeth (2006). Redefining Health Care: Creating Value-Based Competition on Results. Boston: Harvard Business School Press. ISBN 1-59139-778-2.
- Gibson, Rosemary; Prasad Singh, Janardan (2003). Wall of Silence: The Untold Story of the Medical Mistakes That Kill and Injure Millions of Americans. Washington D.C.: Regnery. ISBN 978-0895261120.
- Alldred D.P., Standage C., Zermansky A.G., Jesson B., Savage I., Franklin B.D., Barber N., Raynor D.K.; Standage; Zermansky; Jesson; Savage; Franklin; Barber; Raynor (2008). "Development and validation of criteria to identify medication-monitoring errors in care home residents". International Journal of Pharmacy Practice 16 (5): 317–323. doi:10.1211/ijpp.16.5.0007.
- National Academies of Sciences, Engineering, and Medicine (2015). Improving Diagnosis in Health Care. Washington, DC: The National Academies Press. doi:10.17226/21794. ISBN 978-0-309-37769-0.
- Patient safety at DMOZ
- Medical Errors & Patient Safety from U.S. Dept. of Health & Human Services, Agency for Healthcare Research and Quality
- Dead by Mistake - Dead by Mistake - Hearst Newspapers Report, August 2009
- Report to the President on Medical Errors from February 2000
- Information on Medical Errors from medstat-info.org
- Report on Medical Errors from Consumers Union May 19, 2009
- The Savvy Patient Toolkit to help minimize errors
- Medical Misdiagnosis in the NHS