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Patient safety comes first
reports that put forth a blueprint of actions 
 from National Academy of Sciences. Sciences Engineering Medicine (Health and Medicine Division)
Keeping Patients Safe:
Transforming the Work Environment of Nurse
Nurses are linked to patient safety by
Adhereing the Nursing standards
Transformational leadership by implementing evidence-based management
Proper staffing levels
Design of work environment to mitigate errors
Available from: https://www.ncbi.nlm.nih.gov/books/NBK216190/doi: 10.17226/10851
TO ERR IS HUMAN:BUILDING A SAFER HEALTH SYSTEM
Preventable medical errors in hospitals can be avoided.An estimate of 44,000 to 98,000 people die in facilities
Changes were needed to organizations

The full text of this report is available at
http://www.nap.edu/books/0309068371/html/
Adressed 6 aims for U.S.Healthcare by: 
redesign care processes
make effective use of information technologies manage clinical knowledge and skills 
develop effective teams
coordinate care across patient conditions, services, and settings over time
 incorporate performance and outcome measurements for improvement and accountability
Types of Errors 
Error or delay in diagnosis
Failure to employ indicated tests
Use of outmoded tests or therapy
Failure to act on results of monitoring or testing
Treatment
Error in the performance of an operation, procedure, or test
Error in administering the treatment
Error in the dose or method of using a drug
Avoidable delay in treatment or in responding to an abnormal test 
Inappropriate (not indicated) care
Preventive
Failure to provide prophylactic treatment 
Inadequate monitoring or follow-up of treatment
Other
Failure of communication 
Equipment failure
Other system failure

SOURCE: Leape, Lucian; Lawthers, Ann G.; Brennan, Troyen A., et al. Pr e- venting Medical Injury. Qual Rev Bull. 19(5):144–149, 1993.
    
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