1;Contents;8
2;Acknowledgments;10
3;About the author;12
4;Abbreviations;14
5;1 An overview and introduction to concepts;16
5.1;1.1 Introduction;16
5.2;1.2 Medical error;17
5.3;1.3 Magnitude and epidemiology of health care errors;19
5.4;1.4 Conclusion;23
6;2 Perceptions of medical error and adverse events;26
6.1;2.1 Introduction;26
6.2;2.2 Perceptions by physicians;27
6.3;2.3 Perceptions by the public;28
6.4;2.4 Perceptions by health care staff;30
6.5;2.5 Perceptions by medical students;32
6.6;2.6 A sociological perception of medical error;34
6.7;2.7 Conclusion;35
7;3 Causes of medical error and adverse events;38
7.1;3.1 Introduction;38
7.2;3.2 The cognitive influence on error-generating behavior;42
7.3;3.3 Conclusion;43
8;4 Medical error and strategies for working solutions in clinical diagnostic laboratories and other health care areas;46
8.1;4.1 Introduction;46
8.2;4.2 Clinical diagnostic laboratories;47
8.3;4.3 Errors in different stages of analysis;49
8.4;4.4 Strategies for identification and prevention of errors;51
8.5;4.5 Errors in emergency medicine;53
8.6;4.6 Errors in intensive care medicine;56
8.7;4.7 Conclusion;60
9;5 Creating a culture for medical error reduction;66
9.1;5.1 Introduction;66
9.2;5.2 Education and professional development;67
9.3;5.3 Error reporting systems;72
9.4;5.4 Leadership and regulatory issues;74
9.5;5.5 Establishing a quality care council;75
9.6;5.6 Emotional impact of errors on health care professionals;76
9.7;5.7 Conclusion;76
10;6 Improving quality in clinical diagnostic laboratories;80
10.1;6.1 Introduction;80
10.2;6.2 Efforts and programs to ensure quality in clinical diagnostic laboratories;81
10.3;6.3 Proficiency testing in clinical laboratories;84
10.4;6.4 External quality assessment and proficiency testing programs;85
10.5;6.5 "No-fault" model;87
10.6;6.6 Conclusion;88
11;7 Barriers to open disclosure;92
11.1;7.1 Introduction;92
11.2;7.2 How to disclose;92
11.3;7.3 Disclosing errors to multiple patients;93
11.4;7.4 Bioethical viewpoints;94
11.5;7.5 Patient-physician relations;95
11.6;7.6 The dilemma of an apology;96
11.7;7.7 Barriers to full disclosure;98
11.8;7.8 Conclusion;99
12;8 International laws and guidelines addressing error and disclosure;102
12.1;8.1 Introduction;102
12.2;8.2 Disclosing preventable adverse events;102
12.3;8.3 International progress and initiatives;103
12.4;8.4 Conclusion;107
13;9 The value of autopsy in detecting medical error and improving quality;110
13.1;9.1 Introduction;110
13.2;9.2 Error in diagnostic medicine;110
13.3;9.3 Missed diagnosis and discordance;111
13.4;9.4 The value of autopsies;112
13.5;9.5 Autopsy decline and strategies to encourage autopsy;113
13.6;9.6 Conclusion;114
14;10 Total quality management, six-sigma, and health care;118
14.1;10.1 Introduction;118
14.2;10.2 New issues, newer solutions;119
14.3;10.3 The six-sigma structure;121
14.4;10.4 Six-sigma in clinical diagnostic laboratories;123
14.5;10.5 Conclusion;124
15;Index;126