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