Adverse events in healthcare: learning from mistakes

Adverse events in healthcare: learning from mistakes.

Large national reviews of patient charts estimate that approximately 10% of hospital admissions are associated with an adverse event (defined as an injury resulting in prolonged hospitalization, disability or death, caused by healthcare management). Apart from having a significant impact on patient morbidity and mortality, adverse events also result in increased healthcare costs due to longer h...

Critical incidents and adverse events in healthcare

Learning from Others' Mistakes

One often hears the lament that medical care in India lags behind that of developed countries. At times, however, one cannot help but feel that in some ways this is a blessing in disguise, because by the time a particular method of treatment gets accepted and adopted in India, we also have knowledge of its various short-comings. If such information is appropriately made use of, it should enable...

Learning from mistakes.

We re-examine the commonly held view that learning and memory necessarily require potentiation of synapses. A simple neuronal model of self-organized learning with no positive reinforcement is presented. The strongest synapses are selected for propagation of activity. Active synaptic connections are temporarily "tagged" and subsequently depressed if the resulting output turns out to be unsucces...

Learning from other people's mistakes.

Clinical negligence claims are a rich source of risk management material. Although medical practice varies to some extent around the globe, familiar themes can be identified from the cases reported to the Medical Protection Society’s (MPS) Claims Committee. Case reports inevitably focus on the lessons that can be learnt and so tend to be reports where the errors in management are unequivocal. H...