Temporal Trends in Rates of Patient Harm Resulting from Medical Care

Landrigan, Christopher P.; Parry, Gareth; Bones, Catherine B.; Hackbarth, Andrew; Goldmann, Donald A.; Sharek, Paul J.

doi:10.1056/nejmsa1004404

Cited by 1,005 publications

(727 citation statements)

References 25 publications

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“…Recent studies suggest that, despite the increased focus on medical errors and investigation, hospitals are not getting safer (Landrigan et al 2010). While we cannot draw a causal connection from our results to this finding, by improving individuals' ability to learn from prior experience, it may be possible to improve future outcomes.…”

Section: Theoretical Contributions and Managerial Implicationsmentioning

confidence: 99%

Learning from My Success and from Others' Failure: Evidence from Minimally Invasive Cardiac Surgery

Staats

Gino³

2013

Management Science

202

133

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Learning from past experience is central to an organization's adaptation and survival. A key dimension of prior experience is whether an outcome was successful or unsuccessful. Although empirical studies have investigated the effects of success and failure in organizational learning, to date, the phenomenon has received little attention at the individual level. Drawing on attribution theory in psychology, we investigate how individuals learn from their own past experiences with both failure and success and from the experiences of others. For our empirical analyses, we use 10 years of data from 71 cardiothoracic surgeons who completed more than 6,500 procedures using a new technology for cardiac surgery. We find that individuals learn more from their own successes than from their own failures, but they learn more from the failures of others than from others' successes. We also find that individuals' prior successes and others' failures can help individuals overcome their inability to learn from their own failures. Together, these findings offer both theoretical and practical insights into how individuals learn directly from their prior experience and indirectly from the experiences of others. AcknowledgmentsWe thank Mike Luca, Ella Miron-Spektor, Lamar Pierce, and Enno Siemsen for valuable comments on earlier drafts of the paper. We are grateful to Jesper Sørensen, the associate editor, and to the referees who provided constructive and developmental assistance throughout the review process. All errors remain our own.-1 - Learning from My Success and From Others' Failure:Evidence from Minimally Invasive Cardiac Surgery AbstractLearning from past experience is central to an organization's adaptation and survival. A key dimension of prior experience is whether an outcome was successful or unsuccessful. While empirical studies have investigated the effects of success and failure in organizational learning, to date the phenomenon has received little attention at the individual level. Drawing on attribution theory in psychology, we investigate how individuals learn from their own past experiences with both failure and success and from the experiences of others. For our empirical analyses, we use ten years of data from 71 cardiothoracic surgeons who completed over 6,500 procedures using a new technology for cardiac surgery. We find that individuals learn more from their own successes than from their own failures but learn more from the failures of others than from others' successes. We also find that individuals' prior successes and others' failures can help individuals overcome their inability to learn from their own failures. Together, these findings offer both theoretical and practical insights into how individuals learn directly from their prior experience and indirectly from the experiences of others.

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Section: Theoretical Contributions and Managerial Implicationsmentioning

confidence: 99%

Learning from My Success and from Others' Failure: Evidence from Minimally Invasive Cardiac Surgery

Staats

Gino³

2013

Management Science

202

133

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“…1,2 Consistent decreases in adverse events have not been achieved. 3 In this context, increased attention has been placed on high reliability, a concept that includes achieving consistently high performance levels, 4 not only through reducing failures, but also through improving recognition and action when failures occur. 5 High reliability organizations are characterized by real-time operational awareness, recognition of task complexity, use of near-misses to identify improvement targets, deference to expertise, and resilience among individuals throughout the organization.…”

Section: Introductionmentioning

confidence: 99%

“…It has been defined as Bthe cognitive operations allowing clinicians to observe, collect, and analyze information that ultimately leads to an action.^1 3 However, just as clinical reasoning may be considered broader in scope than decision making, sensemaking may be considered broader than clinical reasoning. Sensemaking encompasses not only understanding individual patients, but also making sense of the competing tasks required by a group of patients.…”

Section: Introductionmentioning

confidence: 99%

The Association Between Sensemaking During Physician Team Rounds and Hospitalized Patients’ Outcomes

et al. 2015

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BACKGROUND: Sensemaking is the social act of assigning meaning to ambiguous events. It is recognized as a means to achieve high reliability. We sought to assess sensemaking in daily patient care through examining how inpatient teams round and discuss patients. OBJECTIVE: Our purpose was to assess the association between inpatient physician team sensemaking and hospitalized patients' outcomes, including length of stay (LOS), unnecessary length of stay (ULOS), and complication rates. DESIGN: Eleven inpatient medicine teams' daily rounds were observed for 2 to 4 weeks. Rounds were audiotaped, and field notes taken. Four patient discussions per team were assessed using a standardized Situation, Task, Intent, Concern, Calibrate (STICC) framework. PARTICIPANTS: Inpatient physician teams at the teaching hospitals affiliated with the University of Texas Health Science Center at San Antonio participated in the study. Outcomes of patients admitted to the teams were included. MAIN MEASURES: Sensemaking was assessed based on the order in which patients were seen, purposeful rounding, patient-driven rounding, and individual patient discussions. We assigned teams a score based on the number of STICC elements used in the four patient discussions sampled. The association between sensemaking and outcomes was assessed using Kruskal-Wallis sum rank and Dunn's tests. KEY RESULTS: Teams rounded in several different ways. Five teams rounded purposefully, and four based rounds on patient-driven needs. Purposeful and patient-driven rounds were significantly associated with lower complication rates. Varying the order in which patients were seen and purposefully rounding were significantly associated with lower LOS, and purposeful and patient-driven rounds associated with lower ULOS. Use of a greater number of STICC elements was associated with significantly lower LOS (4.6 vs. 5.7, p=0.01), ULOS (0.3 vs. 0.6, p=0.02), and complications (0.2 vs. 0.5, p=0.0001).CONCLUSIONS: Improving sensemaking may be a strategy for improving patient outcomes, fostering a shared understanding of a patient's clinical trajectory, and enabling high reliability.

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“…However, that did not make the care any better. Two subsequent meticulously performed studies of 2010, albeit with much smaller numbers of patients than in the HMPS, have borne out the estimates in To Err is Human [7,8].…”

Section: Introductionmentioning

confidence: 99%

“…However, hope and reality collided in two reports, one by HHS and the other from Harvard published in 2010 [7,8]. They showed that the number of deaths associated with adverse events in the decade after To Err is Human was not smaller and may have increased.…”

Section: Introductionmentioning

confidence: 99%

Staying Out of Trouble

Levitt

2013

J Digit Imaging

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Temporal Trends in Rates of Patient Harm Resulting from Medical Care

Cited by 1,005 publications

References 25 publications

Learning from My Success and from Others' Failure: Evidence from Minimally Invasive Cardiac Surgery

Learning from My Success and from Others' Failure: Evidence from Minimally Invasive Cardiac Surgery

The Association Between Sensemaking During Physician Team Rounds and Hospitalized Patients’ Outcomes

Staying Out of Trouble

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