Table of Contents

1. Medical Errors: The Scope of the Problem
  An Epidemic of Errors
    Where Errors Occur
    Costs
    Not a New Issue
    Public Fears
    It’s a Systems Problem
    Types of Errors
    Preventing Errors
  Five Steps to Safer Health Care
2. Tips to Help Prevent Medical Errors
  What Are Medical Errors
  What Can You Do? Be Involved in Your Health Care
    Medicines
    Hospital Stays
    Surgery
    Other Steps You Can Take
  Ways You Can Help Your Family Prevent Medical Errors!
    What Are Medical Errors?
    What Can You Do?
3. Helpful Hints for Preventing Medical Errors
  The Problem
  Prevention Tips
    Ways to Minimize Errors
  Thorough and Credible Root Cause Analysis
  Common Error Types and "High-Alert" Medications
    Target Drugs
    Target Procedures
    Points in the Process Where Errors Can Occur
  Resources at Glance
4. Improving Medication Safety
  Background
  Common Sources of Error
  Steps for Improving Medication Safety
  Our Sources
  Books
  Patient Information Brochures
  Information on Safe Medication Practices
  Successful Practices for Improving Medication Safety
    Easily Implemented Changes (Process Design)
    Longer-Term Changes (Systems Redesign)
5. Reducing Errors in Health Care
  Patients at Risk
  How Errors Occur
    Medication Errors
    Surgical Errors
    Diagnostic Inaccuracies
    System Failures
  Improving Patient Safety
    Computerized ADE Monitoring
    Computer-Generated Reminders for Follow-up Testing
    Standardized Protocols
  Promoting Safety
  References
  Recommendations for Identifying and Learning From Errors in Pediatrics
6. Root Cause Analysis
  Background
  Practice Description
    Prevalence and Severity of the Target Safety Problem
    Opportunities for Impact
    Study Designs
    Study Outcomes
    Evidence for Effectiveness of the Practice
    Potential for Harm
    Costs and Implementation
    Comment
    Authors
  Referances
7. Fatigue, Sleepiness, and Medical Errors
  Introduction
  Background
    Sleep Deprivation
    Night Shifts and Shift Rotation
  Prevalence and Severity
  Practice Descriptions
    Hours of Service
    Direction and Speed of Rotation of Shift Work
    Improving Sleep: Education About Sleep Hygiene
    Lighting at Work
    Napping
    Medical Therapies
  Comment
  References