PMID- 19615466
OWN - NLM
STAT- MEDLINE
DCOM- 20111103
LR  - 20131121
IS  - 1532-0480 (Electronic)
IS  - 1532-0464 (Linking)
VI  - 44
IP  - 3
DP  - 2011 Jun
TI  - Adverse events in medicine: easy to count, complicated to understand, and complex 
      to prevent.
PG  - 390-4
LID - 10.1016/j.jbi.2009.06.004 [doi]
AB  - The performance of patient safety initiatives has not met expected targets for 
      reasons that are gradually being understood. They have been too hospital-centered 
      and too process- and "silo"-driven in their search for the causes of adverse 
      events (AEs). Information technology could help overcome many obstacles, but only 
      if the tools developed are based on a relevant safety model. We have applied the 
      distinction between easy, complicated, and complex problems and strategies in 
      healthcare to changes that need to be made in the detection and analysis of AEs. 
      We propose a triple shift: (i) adopting an outcome-driven rather than a 
      process-driven policy when defining and counting AEs (relatively easy), (ii) 
      applying a patient- and not silo-driven approach and extending the timeframe when 
      analyzing AEs (more difficult), and (iii) taking a systemic view of all care 
      delivered to a patient during their life-span in order to erect barriers against 
      the risks identified (highly complex).
CI  - Copyright (c) 2009 Elsevier Inc. All rights reserved.
FAU - Amalberti, Rene
AU  - Amalberti R
AD  - Patient Safety, Haute Autorite de Sante (HAS), 2 Avenue du Stade de France, Saint 
      Denis La Plaine Cedex, France. rene.amalberti@wanadoo.fr
FAU - Benhamou, Dan
AU  - Benhamou D
FAU - Auroy, Yves
AU  - Auroy Y
FAU - Degos, Laurent
AU  - Degos L
LA  - eng
PT  - Journal Article
DEP - 20090715
PL  - United States
TA  - J Biomed Inform
JT  - Journal of biomedical informatics
JID - 100970413
SB  - IM
MH  - Drug-Related Side Effects and Adverse Reactions
MH  - Humans
MH  - Medical Errors/*prevention & control
MH  - Medication Errors/prevention & control
MH  - Quality Assurance, Health Care
MH  - Safety Management/*methods
EDAT- 2009/07/21 09:00
MHDA- 2011/11/04 06:00
CRDT- 2009/07/21 09:00
PHST- 2009/03/18 00:00 [received]
PHST- 2009/06/30 00:00 [revised]
PHST- 2009/06/30 00:00 [accepted]
PHST- 2009/07/21 09:00 [entrez]
PHST- 2009/07/21 09:00 [pubmed]
PHST- 2011/11/04 06:00 [medline]
AID - S1532-0464(09)00093-8 [pii]
AID - 10.1016/j.jbi.2009.06.004 [doi]
PST - ppublish
SO  - J Biomed Inform. 2011 Jun;44(3):390-4. doi: 10.1016/j.jbi.2009.06.004. Epub 2009 
      Jul 15.