Bad Outcomes of Questionable Medical Decisions
Authors: William B. Weeks, James P. Bagian
Journal: Annals of Internal Medicine (2003)

Letters18 March 2003Bad Outcomes of Questionable Medical DecisionsWilliam B. Weeks, MD, MBA and James P. Bagian, MD, PEWilliam B. Weeks, MD, MBANational Center for Patient Safety, Veterans Health Administration, Ann Arbor, MI 05009 (Weeks, Bagian)Search for more papers by this author and James P. Bagian, MD, PENational Center for Patient Safety, Veterans Health Administration, Ann Arbor, MI 05009 (Weeks, Bagian)Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-138-6-200303180-00028 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail TO THE EDITOR:Hofer and Hayward (1) present a case of cascade iatrogenesis to question the efficacy of medical error reporting and root-cause analysis of medical errors. What, they ask, might a root-cause analysis of this case have yielded in terms of improved systems of care?We found a certain irony in the juxtaposition of the authors' conclusion that a root-cause analysis would have only confirmed what is already known in the literature with their argument that priorities for improving patient safety should focus on application in practice of what has been demonstrated to be effective in research settings. Isn't ...References1. Hofer TP, Hayward RA. Are bad outcomes from questionable clinical decisions preventable medical errors? A case of cascade iatrogenesis. Ann Intern Med. 2002;137:327-33. [PMID: 12204016] LinkGoogle Scholar2. DeRosier J, Stalhandske E, Bagian JP, Nudell T. Using health care Failure Mode and Effect Analysis: the VA National Center for Patient Safety's prospective risk analysis system. Jt Comm J Qual Improv. 2002;28:248-67, 209. [PMID: 12053459] MedlineGoogle Scholar3. Bagian JP, Lee C, Gosbee J, DeRosier J, Stalhandske E, Eldridge N, et al. . Developing and deploying a patient safety program in a large health care delivery system: you can't fix what you don't know about. Jt Comm J Qual Improv. 2001;27:522-32. [PMID: 11593886] MedlineGoogle Scholar4. Bagian J. Patient safety: what is the goal and how do we get there? Joint Commission Perspectives on Patient Safety. 2002;2:6. Google Scholar Author, Article, and Disclosure InformationAffiliations: National Center for Patient Safety, Veterans Health Administration, Ann Arbor, MI 05009 (Weeks, Bagian) PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoAre Bad Outcomes from Questionable Clinical Decisions Preventable Medical Errors? A Case of Cascade Iatrogenesis Timothy P. Hofer and Rodney A. Hayward Bad Outcomes of Questionable Medical Decisions Timothy P. Hofer and Rodney A. Hayward Bad Outcomes of Questionable Medical Decisions Kenneth M. Kessler Bad Outcomes of Questionable Medical Decisions Elizabeth Nilson Metrics 18 March 2003Volume 138, Issue 6Page: 520KeywordsCaregiversDecision analysisHealth carePatient advocacySafety ePublished: 18 March 2003 Issue Published: 18 March 2003 Copyright & PermissionsCopyright © 2003 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...