Recommendation Strategy Pursue patient safety initiatives that prevent medical injury Strengthen oversight and accountability mechanisms to better ensure the competencies of physicians and nurses Allow health care researcher access to…

Fig. 33.1 Michael 20 months old, always smiling Fig. 33.2 Michael at age 2 ½ years, being his ‘silly self’ Fig. 33.3 Michael 11 years old, with his younger cousin…

“When patients die in other areas of medicine the question is ‘what happened?’ However, when a patient dies during or after surgery, the question is, ‘what did you do?’”—Peter Angelos…

Fig. 13.1 Department of Health and Human Services organizational chart [7] The federal government works in partnership with state and local agencies, national quality and safety organizations, accrediting organizations, insurers…

Fig. 8.1 Oxyhemoglobin dissociation curve Conventional Wisdom Can Be Harmful The Oxyhemoglobin Dissociation Curve (ODC), discovered in 1903 by Christian Bohr, was changed substantially in the mid 1980s because of…

Fig. 25.1 Errors (incidents) are not the same as adverse events. Only a part of all adverse events are preventable Every undesired outcome of care is a complication, irrespective of…

Fig. 20.1 Surgery and research as the best advocates for patient safety. GCP good clinical practice, GLP good lab practice Traditional surgical research has covered a vast amount of peri-operative…

Old New (2011) Preventable Unanticipated mortality with opportunity for improvement Non-Preventable Mortality without opportunity for improvement Possibly Preventable Anticipated mortality with opportunity for improvement The Institute of Medicine in 1999…

Fig. 31.1 Operating room efficiencies study. These are the results of our local operating room efficiency study. The x axis is the issues studied. The y axis is the frequency…