Titlebook: Making Healthcare Safe; The Story of the Pat Lucian L. Leape Book‘‘‘‘‘‘‘‘ 2021 The Editor(s) (if applicable) and The Author(s) 2021 patient

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The Hidden Epidemic: The Harvard Medical Practice Studytors are in fact sued at some time in their career, whether or not they did anything wrong. For some high-risk specialties, including neurosurgery, vascular surgery, and cardiology, the percentage sued is very high, and multiple suits are not uncommon. For all doctors, the cost of malpractice insura

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Changing the System: The Adverse Drug Events Studyheory and the evidence—and for me it was compelling—the idea of a systems approach to preventing errors would get little acceptance from physicians unless we could demonstrate that it actually worked in healthcare.

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A Home of Our Own: The National Patient Safety Foundationept for Marty Hatlie, the AMA’s legal counsel. Marty was intrigued by the success of the Anesthesia Patient Safety Foundation (APSF) that Jeep Pierce and Jeff Cooper had founded. He envisioned the formation of a similar national organization as the centerpiece of the refashioning of the AMA’s stance

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We Can Do This: The Institute for Healthcare Improvement Adverse Drug Events Collaborative beginning to be developed. Policy-makers and the healthcare establishment were slow to respond to the new information on the extent of medical error and our calls for a new approach, but one person instantly recognized the challenge: Don Berwick of the Institute for Healthcare Improvement (IHI).

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Who Will Lead? The Executive Sessionedical errors.” “What is an Executive Session?” I replied. He then told me about the work he had been involved in at the Harvard Kennedy School of Government (HKS) on juvenile justice and community policing. Developed in the late 1970s at HKS, an executive session is a prolonged confidential convers

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A Community of Concern: The Massachusetts Coalition for the Prevention of Medical Errors said, “We should form a state coalition for the prevention of medical errors.” His idea was to bring to the table the key players in health who tended not to talk much with one another—regulators and the regulated, academics and practitioners, etc.

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The Government Responds: The Agency for Healthcare Research and Qualitynter this emerging field had little to work with: few measures, few proven safe practices, and few standards. For the patient safety movement to blossom in the ways envisioned by the IOM, a substantial amount of foundational work would be necessary. Only the government could provide the resources th

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Enforcing Standards : The Joint Commissionospital, the nation was riveted by the clear and calm account of its progress by the hospital’s physician spokesman, Dennis O’Leary. Five years later, O’Leary became the head of the Joint Commission on Accreditation of Hospitals.

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Partners in Progress: Patient Safety in the UKmary. In response to parents’ complaints, the GMC had launched an investigation into the high mortality of cardiac surgery of children at the Infirmary. It found that of 53 children who were operated on, 29 had died and 4 suffered severe brain damage. Three surgeons were found guilty of serious prof