- Email: [email protected]
Human error in medicine: Promise and pitfalls, part 2
HEALTH POLICY REPORT
Human Error in Medicine: Promise and Pitfalls, Part 2
Human Error in Medicine: Promise and
Robert Woolard, MD
Pitfalls, Part 2
Department of Emergency Medicine
Robert L. Wears, MD, MS Department of Emergency Medicine
Brown University Providence, RI
University of Florida Health Science Center
Address for reprints: Robert L. Wears, MD,
Jacksonville, FL
MS, Department of Emergency Medicine,
Bruce Janiak, MD Department of Emergency Medicine Toledo Hospital Toledo, OH
University of Florida Health Science Center Jacksonville, 655 W 8th Street, Jacksonville, FL
Oregon Health and Sciences University Portland, OR Arthur L. Kellermann, MD, MPH Department of Emergency Medicine Emory University Atlanta, GA Charlotte S. Yeh, MD National Heritage Insurance Company Boston, MA Matthew M. Rice, MD, JD North West Emergency Medicine Physicians Seattle, WA Gregory Jay, MD, PhD Department of Emergency Medicine Brown University Providence, RI
[Wears RL, Janiak B, Moorhead JC, Kellermann AL, Yeh CS, Rice MM, Jay G, Perry SJ, Woolard R. Human error in medicine: promise and pitfalls, part 2. Ann Emerg Med. August 2000;36:142-144.]
32209; 904-549-4124; E-mail [email protected]. Copyright © 2000 by the American College of Emergency Physicians.
John C. Moorhead, MD, MS Department of Emergency Medicine
Human Error in Medicine: Promise and Pitfalls, Part 2
0196-0644/2000/$12.00 + 0 47/1/108713 doi:10.1067/mem.2000.108713
Editor’s note: This article continues the Health Policy Report published in the July 2000 issue of Annals. In part 1, Wears et al described the broad reaction generated by the Institute of Medicine’s (IOM) report, “To Err Is Human: Building a Safer Health System.” Health care professionals, society and its leaders, and health care administrators all face important choices as they respond to the startling data presented by the IOM. The authors described several pitfalls that must be avoided, lest the opportunity to reduce medical errors be squandered. Wears et al now turn to a strategy for action. The IOM report has created an unprecedented opportunity to make great strides in reducing medical errors. To make the most of this opportunity, the medical community must develop a coordinated and thoughtful response. Through these recommendations, Wears et al initiate an important dialogue that must continue among emergency providers, the broader medical community, policymakers, and the public.
Shawna J. Perry, MD Department of Emergency Medicine University of Florida Health Science Center Jacksonville, FL
1 4 2
S T R AT E G Y F O R A C T I O N The Institute of Medicine (IOM) report demands a vigorous and sustained response. Emergency physicians have already taken
ANNALS OF EMERGENCY MEDICINE
36:2 AUGUST 2000
HEALTH POLICY REPORT
some positive steps by investigating modalities that have proven useful in aviation, such as teamwork training,1-4 emergency department simulators,5 and computer-aided, guideline-based ordering,6,7 but much more remains to be done. A plan of attack could follow the wellestablished model of investigating the epidemiology, pathophysiology, and therapeutic/ preventative interventions for a disease process, and could look something like the following. To investigate the epidemiology of error in emergency care, we need first to establish a suitable set of definitions and terms for errors and related events that are relevant to emergency care. This will require broad input, but a reasonable starting point might be to dispense with the value-laden term “error” and concentrate instead on adverse events in emergency care. These could be grouped into 4 classes: preventable, unpreventable, prevented, and absorbed. A preventable adverse event is necessarily a somewhat subjective judgment, and different standards could be used for different purposes. For example, a common standard for a preventable event might be “preventable if known best practices were used,” whereas another might be “preventable if new, different, perhaps better than the current standard practices were used.” Prevented adverse events would be near misses, episodes where an error or incident chain started, but was averted at some point. Absorbed events would be those incidents where there was an error or anomaly, but no harm or injury resulted. By concentrating on events, rather than errors, we admit a broader range of factors into consideration and reduce the temptation to look for a single cause or responsible party. Once events of interest are identified, a method of indexing them so that associations can be inferred will be needed. Because adverse events and errors typically have multiple contributing factors, simple classification schemes (eg, error in diagnosis, treatment, technique) are likely to be too broad and overlapping to be helpful. Instead, attaching a finite but unlimited set of attributes to an event and its causal chain would allow for retrieval of like events across many dimensions. The “pathophysiology” of adverse events can be investigated using well-established
AUGUST 2000
36:2
quality improvement methods, such as root cause analysis, to identify causes and contributing conditions.8,9 Investigations of quality problems in health care have traditionally tended to stop too soon, because they have focused more on the “who” than the “why.” However, the context in which an event occurs is typically more informative than details of the event itself. For example, finding that a clinician did not follow a policy or broke a rule is not a sufficient cause. It is necessary to know why the rule was broken: was it never known, forgotten, counterproductive, not customarily followed, and so on? The Toyota approach of answering “the 5 why’s” (ie, ensuring the causal chain is at least 5 levels deep) should be used to ensure that the investigation does not take the easy way out.10 This will require interdisciplinary effort and a deep understanding of the way work is done, and should include multiple levels: individual cognition, impact of technology, workplace factors, work team interactions, organizational factors, and outside factors. It is very important that we examine the effects of external factors on patient safety. Health care is currently undergoing a wrenching transformation and institutions are under tremendous cost pressures. There is abundant evidence that when fewer people watch more things, they notice less in an attempt to keep up.11 Analysis of the ValuJet crash of 1996 shows how disastrous the unintended consequences of fundamental restructuring of an industry can be.12 Knowledge of the types of errors, their consequences, and a deep knowledge of their causes and contributing conditions will allow the design of effective interventions. This will be a long-term process that ultimately should result in a complete redesign of the way care is delivered in EDs. Several general principles have been identified as powerful means to reduce error and improve quality at the level of process redesign.13 Simplification and standardization of procedures dramatically decrease the complexity of process and the number of things that can go wrong. Reducing reliance on memory and calculation relieves human beings of tasks that in general, we all do poorly. Similarly, reducing reliance on vigilance, which declines rapidly with fatigue and long hours, can reduce errors of inattention. Changes in design that make it difficult or impossible to
ANNALS OF EMERGENCY MEDICINE
err (termed “forcing functions”) can be used. Finally, buffers can be introduced into processes to reduce the tight coupling between an error and its consequences, so that errors that are made are easier to detect and stop before they result in patient injury. However, redesign of work processes by itself will not be enough. Fundamental organizational change is also needed, because unless the organization has a culture that supports understanding and reducing errors, the effects of process changes will be minimal.13 Health care organizations will need to prioritize safety for their work environments. That means establishing safe staffing minimums, limiting work hours, improving the physical work environment, and reducing distractions and interruptions. Improving communication (particularly against the authority gradient), prioritization, and planning by teamwork training can reduce errors and help begin the process of cultural change.2,4 Finally, the culture of blame and punishment will need change to one that is supportive, nonpunitive, and trusting. Voluntary, confidential, protected, and nonpunitive error reporting systems will be effective only if the internal and external culture of individuals and organizations supports it. Even as these changes are accomplished, adverse events and injuries will still occur. Therefore, we also need to address the management of the victims of adverse events and their families. Those affected want 3 things. First, they want to know what happened. There is some evidence that full disclosure of errors, even minor ones, is both desired by patients14 and better for institutions.15,16 Second, they want to hear that we are sorry, that both the institution and people involved feel sincere regret for what happened. And finally, they want to know how we are going to prevent recurrence. A policy of timely, full, honest disclosure of what happened and how it happened is ethically required and will be necessary to establish trust.17 Woods18 has pointed out that a system of mandatory notification and independent investigation by a trusted organization of selected cases of injury would achieve some of the goals sought by those who advocate mandatory reporting, without risking a return to the culture of blame, stonewalling, and secrecy.
1 4 3
HEALTH POLICY REPORT
A “MODEST PROPOSAL” The IOM report recommends the establishment of a national Center for Patient Safety and of multiple Centers of Excellence focused on particular errors or settings. In addition, it asks professional organizations to “… make a visible commitment to patient safety by establishing a permanent committee dedicated to safety improvement.”19 Our professional organizations should begin now to establish the appropriate bodies and contacts so we can build a National Center of Excellence in Emergency Patient Safety, with broad support from all the major organizations and professions involved in emergency care. Such a center should aim to develop knowledge and understanding about how safety is created. Woods18 suggests it should have the following characteristics: 1. It should function exclusively as an advocate for patient safety. Because it will need to be trusted by all parties, it should have no regulatory or enforcement role. Its goal should be learning, not prescribing. 2. Even though it will undoubtedly require government funding, it should be politically independent so that it can remain an advocate for safety, uncontaminated by other agendas, particularly when such advocacy may run counter to the prevailing public winds. 3. A primary mission should be learning how to be safe in emergency care. That is, advocacy is important but it should be more than just a cheerleader. It should generate the technical and evidentiary base to guide improvements. This will require directed research activities, investigation of incidents and near misses, and investigation of actual injuries. 4. It should be interdisciplinary. Physicians do not work in isolation in EDs, but rather in teams with nurses, paramedics, and technicians. All emergency caregivers have something to contribute and should feel they have ownership of the process, or it will fail. In addition, input is needed from fields traditionally outside medical care, such as human performance and organizational behavior. We have taken a few steps in this direction already. Both the Society for Academic Emergency Medicine and the American College of Emergency Physicians have created task forces to develop effective responses congruent with their missions. Academic Emer-
1 4 4
gency Medicine recently hosted a consensus conference. We should extend these efforts to include our colleagues in the Emergency Nurses Association and the Society of Trauma Nurses to create a combined body that could coordinate safety efforts. Emergency medicine is particularly wellsuited to take a leadership role in patient safety by virtue of its relative youth, willingness to change, tradition of patient advocacy, and capacity for inventing effective systems of care where none existed before. Either we can join together, abandon defensiveness, and formulate a productive, multidisciplinary agenda to decrease medical errors in emergency care, or we can passively await legislative and regulatory proposals that will inevitably be more intrusive and less effective in our day-to-day practice.
12. Langewiesche W. The lessons of ValuJet 592. Atlantic Monthly. 1998;281(May):81-98. 13. Leape LL, Kabcenell A, Berwick DM, et al. Reducing Adverse Drug Events and Medical Errors. Boston, MA: Institute for Healthcare Improvement; 1998. 14. Witman AB, Park DM, Hardin SB. How do patients want physicians to handle mistakes? A survey of internal medicine patients in an academic setting. Arch Intern Med. 1996;156:2565-2569. 15. Kraman SS, Hamm G. Risk management: extreme honesty may be the best policy [see comments]. Ann Intern Med. 1999;131:963-937. 16. Wu AW. Handling hospital errors: is disclosure the best defense? [editorial; comment]. Ann Intern Med. 1999;131: 970-972. 17. Wu AW, Cavanaugh TA, McPhee SJ, et al. To tell the truth: ethical and practical issues in disclosing medical mistakes to patients. J Gen Intern Med. 1997;12:770-775. 18. Woods DD. Investing in Patient Safety: Six Points to Create Learning. Columbus, OH: Institute for Ergonomics, Ohio State University; 2000. 19. Kohn LT, Corrigan JM, Donaldson MS, eds. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 1999.
1. Jay G, Risser DT, Rice M, et al. Formal teamwork training improved teamwork and reduced emergency department errors [abstract]. Acad Emerg Med. 1999;6:408. 2. Risser DT, Rice MM, Salisbury ML, et al. The potential for improved teamwork to reduce medical errors in the emergency department. The MedTeams Research Consortium [see comments]. Ann Emerg Med. 1999;34:373-383. 3. Simon R, Morey JC, Rice M, et al. Reducing errors in emergency medicine through team performance: the MedTeams project. In: Proceedings of the Second Annenberg Conference on Enhancing Patient Safety and Reducing Errors in Health Care. Rancho Mirage, CA: National Patient Safety Foundation; 1998:142-146. 4. Risser DT, Simon R, Rice MM, et al. A structured teamwork system to reduce clinical errors. In: Spath PL, ed. Error Reduction in Health Care: A Systems Approach to Improving Patient Safety. San Francisco, CA: JosseyBass Publishers; 1999:235-78. 5. Small SD, Wuerz RC, Simon R, et al. Demonstration of high-fidelity simulation team training for emergency medicine. Acad Emerg Med. 1999;6:312-323. 6. Schriger DL, Baraff LJ, Rogers WH, et al. Implementation of clinical guidelines using a computer charting system. Effect on the initial care of health care workers exposed to body fluids [see comments]. JAMA. 1997;278:1585-1590. 7. Schriger DL, Baraff LJ, Buller K, et al. Implementation of clinical guidelines via a computer charting system: effect on the care of febrile children less than three years of age [inprocess citation]. J Am Med Inform Assoc. 2000;7:186195. 8. Berwick DM, Godfrey AB, Roessner J. Curing Health Care: New Strategies for Quality Improvement. San Francisco, CA: Jossey-Bass Publishers; 1990. 9. Spath PL, ed. Error Reduction in Health Care: A Systems Approach to Improving Patient Safety. San Francisco: Jossey-Bass Publishers; 1999. 10. Womack JP, Jones DT, Roos D. The Machine That Changed the World. New York, NY: HarperCollins Publishers; 1990. 11. Weick KE, Sutcliffe KM, Obstfeld D. Organizing for high reliability: processes of collective mindfulness. In: Staw B, Sutton R, eds. Research in Organizational Behavior: JAI Press; 1999.
ANNALS OF EMERGENCY MEDICINE
36:2 AUGUST 2000
Human Error in Medicine: Promise and Pitfalls, Part 2
Human Error in Medicine: Promise and
Robert Woolard, MD
Pitfalls, Part 2
Department of Emergency Medicine
Robert L. Wears, MD, MS Department of Emergency Medicine
Brown University Providence, RI
University of Florida Health Science Center
Address for reprints: Robert L. Wears, MD,
Jacksonville, FL
MS, Department of Emergency Medicine,
Bruce Janiak, MD Department of Emergency Medicine Toledo Hospital Toledo, OH
University of Florida Health Science Center Jacksonville, 655 W 8th Street, Jacksonville, FL
Oregon Health and Sciences University Portland, OR Arthur L. Kellermann, MD, MPH Department of Emergency Medicine Emory University Atlanta, GA Charlotte S. Yeh, MD National Heritage Insurance Company Boston, MA Matthew M. Rice, MD, JD North West Emergency Medicine Physicians Seattle, WA Gregory Jay, MD, PhD Department of Emergency Medicine Brown University Providence, RI
[Wears RL, Janiak B, Moorhead JC, Kellermann AL, Yeh CS, Rice MM, Jay G, Perry SJ, Woolard R. Human error in medicine: promise and pitfalls, part 2. Ann Emerg Med. August 2000;36:142-144.]
32209; 904-549-4124; E-mail [email protected]. Copyright © 2000 by the American College of Emergency Physicians.
John C. Moorhead, MD, MS Department of Emergency Medicine
Human Error in Medicine: Promise and Pitfalls, Part 2
0196-0644/2000/$12.00 + 0 47/1/108713 doi:10.1067/mem.2000.108713
Editor’s note: This article continues the Health Policy Report published in the July 2000 issue of Annals. In part 1, Wears et al described the broad reaction generated by the Institute of Medicine’s (IOM) report, “To Err Is Human: Building a Safer Health System.” Health care professionals, society and its leaders, and health care administrators all face important choices as they respond to the startling data presented by the IOM. The authors described several pitfalls that must be avoided, lest the opportunity to reduce medical errors be squandered. Wears et al now turn to a strategy for action. The IOM report has created an unprecedented opportunity to make great strides in reducing medical errors. To make the most of this opportunity, the medical community must develop a coordinated and thoughtful response. Through these recommendations, Wears et al initiate an important dialogue that must continue among emergency providers, the broader medical community, policymakers, and the public.
Shawna J. Perry, MD Department of Emergency Medicine University of Florida Health Science Center Jacksonville, FL
1 4 2
S T R AT E G Y F O R A C T I O N The Institute of Medicine (IOM) report demands a vigorous and sustained response. Emergency physicians have already taken
ANNALS OF EMERGENCY MEDICINE
36:2 AUGUST 2000
HEALTH POLICY REPORT
some positive steps by investigating modalities that have proven useful in aviation, such as teamwork training,1-4 emergency department simulators,5 and computer-aided, guideline-based ordering,6,7 but much more remains to be done. A plan of attack could follow the wellestablished model of investigating the epidemiology, pathophysiology, and therapeutic/ preventative interventions for a disease process, and could look something like the following. To investigate the epidemiology of error in emergency care, we need first to establish a suitable set of definitions and terms for errors and related events that are relevant to emergency care. This will require broad input, but a reasonable starting point might be to dispense with the value-laden term “error” and concentrate instead on adverse events in emergency care. These could be grouped into 4 classes: preventable, unpreventable, prevented, and absorbed. A preventable adverse event is necessarily a somewhat subjective judgment, and different standards could be used for different purposes. For example, a common standard for a preventable event might be “preventable if known best practices were used,” whereas another might be “preventable if new, different, perhaps better than the current standard practices were used.” Prevented adverse events would be near misses, episodes where an error or incident chain started, but was averted at some point. Absorbed events would be those incidents where there was an error or anomaly, but no harm or injury resulted. By concentrating on events, rather than errors, we admit a broader range of factors into consideration and reduce the temptation to look for a single cause or responsible party. Once events of interest are identified, a method of indexing them so that associations can be inferred will be needed. Because adverse events and errors typically have multiple contributing factors, simple classification schemes (eg, error in diagnosis, treatment, technique) are likely to be too broad and overlapping to be helpful. Instead, attaching a finite but unlimited set of attributes to an event and its causal chain would allow for retrieval of like events across many dimensions. The “pathophysiology” of adverse events can be investigated using well-established
AUGUST 2000
36:2
quality improvement methods, such as root cause analysis, to identify causes and contributing conditions.8,9 Investigations of quality problems in health care have traditionally tended to stop too soon, because they have focused more on the “who” than the “why.” However, the context in which an event occurs is typically more informative than details of the event itself. For example, finding that a clinician did not follow a policy or broke a rule is not a sufficient cause. It is necessary to know why the rule was broken: was it never known, forgotten, counterproductive, not customarily followed, and so on? The Toyota approach of answering “the 5 why’s” (ie, ensuring the causal chain is at least 5 levels deep) should be used to ensure that the investigation does not take the easy way out.10 This will require interdisciplinary effort and a deep understanding of the way work is done, and should include multiple levels: individual cognition, impact of technology, workplace factors, work team interactions, organizational factors, and outside factors. It is very important that we examine the effects of external factors on patient safety. Health care is currently undergoing a wrenching transformation and institutions are under tremendous cost pressures. There is abundant evidence that when fewer people watch more things, they notice less in an attempt to keep up.11 Analysis of the ValuJet crash of 1996 shows how disastrous the unintended consequences of fundamental restructuring of an industry can be.12 Knowledge of the types of errors, their consequences, and a deep knowledge of their causes and contributing conditions will allow the design of effective interventions. This will be a long-term process that ultimately should result in a complete redesign of the way care is delivered in EDs. Several general principles have been identified as powerful means to reduce error and improve quality at the level of process redesign.13 Simplification and standardization of procedures dramatically decrease the complexity of process and the number of things that can go wrong. Reducing reliance on memory and calculation relieves human beings of tasks that in general, we all do poorly. Similarly, reducing reliance on vigilance, which declines rapidly with fatigue and long hours, can reduce errors of inattention. Changes in design that make it difficult or impossible to
ANNALS OF EMERGENCY MEDICINE
err (termed “forcing functions”) can be used. Finally, buffers can be introduced into processes to reduce the tight coupling between an error and its consequences, so that errors that are made are easier to detect and stop before they result in patient injury. However, redesign of work processes by itself will not be enough. Fundamental organizational change is also needed, because unless the organization has a culture that supports understanding and reducing errors, the effects of process changes will be minimal.13 Health care organizations will need to prioritize safety for their work environments. That means establishing safe staffing minimums, limiting work hours, improving the physical work environment, and reducing distractions and interruptions. Improving communication (particularly against the authority gradient), prioritization, and planning by teamwork training can reduce errors and help begin the process of cultural change.2,4 Finally, the culture of blame and punishment will need change to one that is supportive, nonpunitive, and trusting. Voluntary, confidential, protected, and nonpunitive error reporting systems will be effective only if the internal and external culture of individuals and organizations supports it. Even as these changes are accomplished, adverse events and injuries will still occur. Therefore, we also need to address the management of the victims of adverse events and their families. Those affected want 3 things. First, they want to know what happened. There is some evidence that full disclosure of errors, even minor ones, is both desired by patients14 and better for institutions.15,16 Second, they want to hear that we are sorry, that both the institution and people involved feel sincere regret for what happened. And finally, they want to know how we are going to prevent recurrence. A policy of timely, full, honest disclosure of what happened and how it happened is ethically required and will be necessary to establish trust.17 Woods18 has pointed out that a system of mandatory notification and independent investigation by a trusted organization of selected cases of injury would achieve some of the goals sought by those who advocate mandatory reporting, without risking a return to the culture of blame, stonewalling, and secrecy.
1 4 3
HEALTH POLICY REPORT
A “MODEST PROPOSAL” The IOM report recommends the establishment of a national Center for Patient Safety and of multiple Centers of Excellence focused on particular errors or settings. In addition, it asks professional organizations to “… make a visible commitment to patient safety by establishing a permanent committee dedicated to safety improvement.”19 Our professional organizations should begin now to establish the appropriate bodies and contacts so we can build a National Center of Excellence in Emergency Patient Safety, with broad support from all the major organizations and professions involved in emergency care. Such a center should aim to develop knowledge and understanding about how safety is created. Woods18 suggests it should have the following characteristics: 1. It should function exclusively as an advocate for patient safety. Because it will need to be trusted by all parties, it should have no regulatory or enforcement role. Its goal should be learning, not prescribing. 2. Even though it will undoubtedly require government funding, it should be politically independent so that it can remain an advocate for safety, uncontaminated by other agendas, particularly when such advocacy may run counter to the prevailing public winds. 3. A primary mission should be learning how to be safe in emergency care. That is, advocacy is important but it should be more than just a cheerleader. It should generate the technical and evidentiary base to guide improvements. This will require directed research activities, investigation of incidents and near misses, and investigation of actual injuries. 4. It should be interdisciplinary. Physicians do not work in isolation in EDs, but rather in teams with nurses, paramedics, and technicians. All emergency caregivers have something to contribute and should feel they have ownership of the process, or it will fail. In addition, input is needed from fields traditionally outside medical care, such as human performance and organizational behavior. We have taken a few steps in this direction already. Both the Society for Academic Emergency Medicine and the American College of Emergency Physicians have created task forces to develop effective responses congruent with their missions. Academic Emer-
1 4 4
gency Medicine recently hosted a consensus conference. We should extend these efforts to include our colleagues in the Emergency Nurses Association and the Society of Trauma Nurses to create a combined body that could coordinate safety efforts. Emergency medicine is particularly wellsuited to take a leadership role in patient safety by virtue of its relative youth, willingness to change, tradition of patient advocacy, and capacity for inventing effective systems of care where none existed before. Either we can join together, abandon defensiveness, and formulate a productive, multidisciplinary agenda to decrease medical errors in emergency care, or we can passively await legislative and regulatory proposals that will inevitably be more intrusive and less effective in our day-to-day practice.
12. Langewiesche W. The lessons of ValuJet 592. Atlantic Monthly. 1998;281(May):81-98. 13. Leape LL, Kabcenell A, Berwick DM, et al. Reducing Adverse Drug Events and Medical Errors. Boston, MA: Institute for Healthcare Improvement; 1998. 14. Witman AB, Park DM, Hardin SB. How do patients want physicians to handle mistakes? A survey of internal medicine patients in an academic setting. Arch Intern Med. 1996;156:2565-2569. 15. Kraman SS, Hamm G. Risk management: extreme honesty may be the best policy [see comments]. Ann Intern Med. 1999;131:963-937. 16. Wu AW. Handling hospital errors: is disclosure the best defense? [editorial; comment]. Ann Intern Med. 1999;131: 970-972. 17. Wu AW, Cavanaugh TA, McPhee SJ, et al. To tell the truth: ethical and practical issues in disclosing medical mistakes to patients. J Gen Intern Med. 1997;12:770-775. 18. Woods DD. Investing in Patient Safety: Six Points to Create Learning. Columbus, OH: Institute for Ergonomics, Ohio State University; 2000. 19. Kohn LT, Corrigan JM, Donaldson MS, eds. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 1999.
1. Jay G, Risser DT, Rice M, et al. Formal teamwork training improved teamwork and reduced emergency department errors [abstract]. Acad Emerg Med. 1999;6:408. 2. Risser DT, Rice MM, Salisbury ML, et al. The potential for improved teamwork to reduce medical errors in the emergency department. The MedTeams Research Consortium [see comments]. Ann Emerg Med. 1999;34:373-383. 3. Simon R, Morey JC, Rice M, et al. Reducing errors in emergency medicine through team performance: the MedTeams project. In: Proceedings of the Second Annenberg Conference on Enhancing Patient Safety and Reducing Errors in Health Care. Rancho Mirage, CA: National Patient Safety Foundation; 1998:142-146. 4. Risser DT, Simon R, Rice MM, et al. A structured teamwork system to reduce clinical errors. In: Spath PL, ed. Error Reduction in Health Care: A Systems Approach to Improving Patient Safety. San Francisco, CA: JosseyBass Publishers; 1999:235-78. 5. Small SD, Wuerz RC, Simon R, et al. Demonstration of high-fidelity simulation team training for emergency medicine. Acad Emerg Med. 1999;6:312-323. 6. Schriger DL, Baraff LJ, Rogers WH, et al. Implementation of clinical guidelines using a computer charting system. Effect on the initial care of health care workers exposed to body fluids [see comments]. JAMA. 1997;278:1585-1590. 7. Schriger DL, Baraff LJ, Buller K, et al. Implementation of clinical guidelines via a computer charting system: effect on the care of febrile children less than three years of age [inprocess citation]. J Am Med Inform Assoc. 2000;7:186195. 8. Berwick DM, Godfrey AB, Roessner J. Curing Health Care: New Strategies for Quality Improvement. San Francisco, CA: Jossey-Bass Publishers; 1990. 9. Spath PL, ed. Error Reduction in Health Care: A Systems Approach to Improving Patient Safety. San Francisco: Jossey-Bass Publishers; 1999. 10. Womack JP, Jones DT, Roos D. The Machine That Changed the World. New York, NY: HarperCollins Publishers; 1990. 11. Weick KE, Sutcliffe KM, Obstfeld D. Organizing for high reliability: processes of collective mindfulness. In: Staw B, Sutton R, eds. Research in Organizational Behavior: JAI Press; 1999.
ANNALS OF EMERGENCY MEDICINE
36:2 AUGUST 2000