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9 Harvard Medical Practice Study 2), (1) (2) (3) (1) (2) (3) 3 To err is Human 20 9
10 Heinlich Heinlich ) , %, 61.1%, 3.4% (31.4%) 12.9% 72.4% (15.7%) (6.3%) 3.2%,2,3,10-12) (Institute of Medicine, IOM) To Err is Human: Building a Safer Health System 13) 300, 3,14-16) % % 44,000-98,000 Clinton 17) 12 18,19 To Err is Human IOM 10
11 Quality in Australia Health Care Study 28 14, % 13.7% 4.9% 51 3) British Medical Journal Reducing error, Improving safety 21 20) 1) (1) (2) (3) (4) (5) (6) 3,18,19,21-23) 11
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29 3) ) ) ) ). 51:29-78,1999 8). Books ) htm1 10) ) TA Brennan et al.:incidence of adverse events and negligence in hosipitalized patients. Results of the Harvard Medical Practice Study I. NEJM 324: , ) LL Leape et al.:the nature of adverse events in hospitalized patients. Results of the Harvard Medical Prictice Study I NEJM 324: , ) 13. Institute of Medicine: To err Is Human: Building a Safer Health System. National Academy Press ) CJ McDonald et al.:deaths due to medical errors are exaggerated in institute of medical report. JAMA 284:93-95, ) LL Leape:Institute of medicine medical error figures are not exaggerated. JAMA 284:95-97, ) TA Brennan: The institute of medicine report on medical errors-could it do harm. NEJM 342: , ) F Charatan:Clinton acts to reduce medical mistakes. BMJ 320:597, ) To err is human
30 2 19). 5: , ) Reducing error. Improving safety. BMJ 320: , ). 124: , ) ). 4034:73-75, ) SN Weingart et al.:epidemiology of medical error. BMJ 320: , ). 8:5-16, ) ) ) Jpn J Radiol Technol 56 29) ) 122: , ) ) )
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