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Volume 36 | Issue 4 | April 2010
In a widely publicized case, a medication error led to the death of a 16-year-old patient and the termination and criminal prosecution of the nurse involved in the incident. Since then, the nurse has been working with patient safety leaders to help patients, caregivers, and hospitals learn how to promote a culture of safety. In this issue, Smetzer et al. provide the key findings of a root cause analysis regarding the event and subsequent recommendations, as well as the hospital president’s commentary. Editorials address the implications of the case for systems thinking, a safe practice for the care of caregivers associated with unintentional patient harm, and the need to identify and addresss performance problems.
Editorial
We Have Newton on a Retainer: Reductionism When We Need Systems Thinking
Sidney W.A. Dekker, Ph.D.
The Missing Safe Practice
Charles R. Denham, M.D.
Who’s to Blame?
Lucian L. Leape, M.D.
Root Cause Analysis
Shaping Systems for Better Behavioral Choices: Lessons Learned from a Fatal Medication Error
Judy Smetzer, R.N., B.S.N.; Christine Baker, R.N., Ph.D.; Frank D. Byrne, M.D.; Michael R. Cohen, R.Ph., M.S., Sc.D.
Features
Performance Measures
When Tight Blood Pressure Control Is Not for Everyone: A New Model for Performance Measurement in Hypertension
Michael A. Steinman, M.D.; Mary K. Goldstein, M.D.
Infection Prevention and Control
Pertussis and Patient Safety: Implementing Tdap Vaccine Recommendations in Hospitals
Tina Q. Tan, M.D.; Melvin V. Gerbie, M.D.
Timeliness and Efficiency
Clinical Information System and Process Redesign Improves Emergency Department Efficiency
Kevin M. Baumlin, M.D.; Jason S. Shapiro, M.D., M.A.; Corey Weiner, M.D.; Brett Gottlieb; Neal Chawla, M.D.; Lynne D. Richardson, M.D.
Department
Commentary
Health Care Serial Murder: A Patient Safety Orphan
Kenneth W. Kizer, M.D., M.P.H.; Beatrice C. Yorker, J.D., R.N., M.S.
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