Misadventures in health care : inside stories

Series Foreword ix Marilyn Sue Bogner Foreword xi Alphonse Chapanis Preface: The Other Perspective xv Contributors xxi 1 Understanding Human Error 1 Marilyn Sue Bogner 2 The Trouble With Blood Is It All Looks the Same: 13 Transfusion Errors Jeanne V. Linden 3 Stopping Bad Things From Happening to Good People 27 in Shock Trauma Centers Colin F. Mackenzie and Yan Xiao 4 Misadventures in General Surgery 41 Ramon Berguer 5 Safety and Error Issues in Minimally Invasive Surgery 59 Christine L. MacKenzie, Alan J. Lomax, and Jennifer A. Ibbotson 6 The Laparoscopic Surgeon’s Posture 75 Ulrich Matern 7 Anesthesia Incidents and Accidents 89 Matthew B. Weinger 8 The Trojan Horse of the Operating Room: 105 Alarms and the Noise of Anesthesia F. Jacob Seagull and Penelope M. Sanderson 9 The Intensive Care Unit May Be Harmful to Your Health 127 Yoel Donchin 10 Challenges and Adverse Events in the Home 145 Denise M. Korniewicz and Maher El-Masri 11 Aging, Cognition, and Patient Errors in Following 165 Medical Instructions Denise C. Park and Ian Skurnik 12 Prescription for Error: Can Health Care Providers Really 183 “Do No Harm”? Kenneth Dandurand 13 All the Men and Women Merely Players 201 Marilyn Sue Bogner Author Index 215 Subject Index 225 viii CONTENTS6 The Laparoscopic Surgeon’s Posture 75 Ulrich Matern 7 Anesthesia Incidents and Accidents 89 Matthew B. Weinger 8 The Trojan Horse of the Operating Room: 105 Alarms and the Noise of Anesthesia F. Jacob Seagull and Penelope M. Sanderson 9 The Intensive Care Unit May Be Harmful to Your Health 127 Yoel Donchin 10 Challenges and Adverse Events in the Home 145 Denise M. Korniewicz and Maher El-Masri 11 Aging, Cognition, and Patient Errors in Following 165 Medical Instructions Denise C. Park and Ian Skurnik 12 Prescription for Error: Can Health Care Providers Really 183 “Do No Harm”? Kenneth Dandurand 13 All the Men and Women Merely Players 201 Marilyn Sue Bogner Author Index 215 Subject Index 225