Books, Journals, New Media Section Editor:
Harriet S. Meyer, MD, Contributing Editor, JAMA;
David H. Morse, MS, University of Southern California, Norris Medical Library,
Journal Review Editor; adviser for new media, Robert Hogan, MD, San Diego.
This call-to-action proceedings succeeds in presenting the flavor and
content of a complex multidisciplinary assault on inadvertent injury of hospitalized
patients. While it assumes that the reader has greater than average knowledge
of how human error is facilitated and made more lethal by organizational flaws,
most of the quoted speakers provide some scientific background for the topics
that they discuss.
With many of the chapters in a how-to mode—eg, "Taking Action
to Improve Safety," "Creating a Culture of Safety," "Organizational Change,"
"Methodologies for Reporting Adverse Events"—physicians and care managers
are urged to approach analysis of error and of facility system deficit differently
than in the past. Lessons from study of high safety reliability attained in
some industries, the US Navy, and the National Aeronautics and Space Administration
point to many possibilities for change in hospital staff attitudes and methodology.
Patient Safety. JAMA. 2000;284(7):891. doi:10.1001/jama.284.7.891