To Err is Human: Can American Medicine Learn from Past Mistakes?

Ritterman, Jeffrey B.

doi:10.7812/tpp/16-181

Cited by 9 publications

(6 citation statements)

References 42 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…Interestingly, studies conducted in the mid-1930s on cadavers from ill or malnourished patients revealed that the thymus of these subjects was indeed smaller than those of healthy individuals of the same age [47][48][49]. These new findings not only acquitted the thymus from any role in SIDS, but also opened the door to better understand the physiology and role of the thymus [50]. Furthermore, subjects that have undergone 'precautious' irradiation in their younger age were later shown to exhibit higher thyroid malignancy and breast cancer risk [51,52].…”

Section: Acute Thymic Atrophymentioning

confidence: 99%

Thymic Rejuvenation: Are We There Yet?

Abusarah¹,

Khodayarian²,

Cui³

et al. 2018

Gerontology

View full text Add to dashboard Cite

Vaccination is an appealing form of immunotherapy for frail senior patients. However, several studies have shown that in contrast to younger adults, older patients do not effectively respond to vaccines. This phenomenon is greatly attributed to immunosenescence, a hallmark of aging defined by a general decline in immunity caused by thymic involution. Historically, the study of thymic involution brought to attention several factors and components involved in thymopoiesis, as contributors to the phenomena. Depicting the underlying cause(s) of the dramatic changes in the production and properties of the naïve T-cell pool in the event of acute thymic injury or due to inovulation can therefore, help focus the efforts on the best strategy to reverse or overcome these hurdles. Here, we discuss some of the well-studied approaches for rejuvenating the thymus, and introduce interleukin-(IL) 21 as the most recent thymo-stimulatory agent in the field.

show abstract

Section: Acute Thymic Atrophymentioning

confidence: 99%

Thymic Rejuvenation: Are We There Yet?

Abusarah¹,

Khodayarian²,

Cui³

et al. 2018

Gerontology

View full text Add to dashboard Cite

show abstract

“…Therefore, we will need a cultural shift in medicine 94. The traditional culture of shame and blame aimed at HCPs who have experienced an SV phenomenon should be rapidly replaced by a movement toward a “just culture”.…”

Section: Change In Medical Culturementioning

confidence: 99%

“…However, we need also to take steps to reassure patients and rebuild public trust in our efforts 32,95–98. The more humble the medical profession is, the more likely we will avoid costly errors 94,95. We should explain more to the public, as described in the book “To Err is Human”, People working at HC are not bad people, they are good people who are trying to make bad systems safer 99.…”

Section: Change In Medical Culturementioning

confidence: 99%

<p>Second victims in health care: current perspectives</p>

Özeke¹,

Özeke

Çoşkun

et al. 2019

AMEP

113

109

View full text Add to dashboard Cite

Medical errors are a serious public health problem and the third-leading cause of death after heart disease and cancer. Every day, the health care professionals (HCPs) practice their skill and knowledge within excessively complex situations and meet unexpected patient outcomes. These unexpected complications and unintentional errors will always be a part of the medical system due to the universal nature of human fallibility and technology. While not all errors are life-threatening, they can significantly compromise a patient’s quality of life. However, the victims of medical error reach far beyond the patient. The second victim (SV), which defined for the first time by Albert Wu in his description of the impact of errors on HCPs by both personally and professionally, is a medical emergency equivalent to post-traumatic stress disorder. When the errors occur, it causes a domino effect including the four groups: the patient and family (first victim), the HCP [SV], the hospital reputation (third victim), and patients who are harmed subsequently (fourth victims). The rights of our patients to safe, reliable, and patient-centered care are critical and most important as a primary and utmost aim of medicine. However, we also have to take care of our own (SVs), especially when we have good people who mean to do well and then ﬁnd themselves in an emotionally complex situation. There is a need to articulate to the public, politicians, and media how system failure leads to medical error even in hand of well-educated and competent HCPs are given an increasing clinical workload. Furthermore, despite several leading institutions in western countries have developed formal support programs that allow HCPs to cope with their emotional distress by obtaining timely support in an emphatic, confidential, non-judgmental environment, we need to raise awareness of this phenomenon and appropriate institutional responses both to harmed patients and their families and HCPs.

show abstract

“…This may cause harm. Poor reasoning and data collection resulted in radiation treatment of children to prevent sudden infant death syndrome in the early 1900s, resulting in >10,000 babies dying of thyroid cancer (71).…”

Section: The Prevalence and Consequences Of Errorsmentioning

confidence: 99%

Issues with data and analyses: Errors, underlying themes, and potential solutions

Brown

Kaiser

Allison

2018

Proc. Natl. Acad. Sci. U.S.A.

134

102

View full text Add to dashboard Cite

Some aspects of science, taken at the broadest level, are universal in empirical research. These include collecting, analyzing, and reporting data. In each of these aspects, errors can and do occur. In this work, we first discuss the importance of focusing on statistical and data errors to continually improve the practice of science. We then describe underlying themes of the types of errors and postulate contributing factors. To do so, we describe a case series of relatively severe data and statistical errors coupled with surveys of some types of errors to better characterize the magnitude, frequency, and trends. Having examined these errors, we then discuss the consequences of specific errors or classes of errors. Finally, given the extracted themes, we discuss methodological, cultural, and systemlevel approaches to reducing the frequency of commonly observed errors. These approaches will plausibly contribute to the self-critical, self-correcting, ever-evolving practice of science, and ultimately to furthering knowledge.rigor | statistical errors | quality control | reproducibility | data analysis

show abstract

To Err is Human: Can American Medicine Learn from Past Mistakes?

Cited by 9 publications

References 42 publications

Thymic Rejuvenation: Are We There Yet?

Thymic Rejuvenation: Are We There Yet?

<p>Second victims in health care: current perspectives</p>

Issues with data and analyses: Errors, underlying themes, and potential solutions

Contact Info

Product

Resources

About