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2002
Fourth Annual SIH/SIU Health Policy Institute
Patient Safety and Medical Errors: Reporting and Disclosure
Issues (May 30 and 31, 2002)
Patient Safety and Medical Errors: Reporting and Disclosure
Issues
“Non-punitive, protected voluntary incident reporting systems in
high risk non-medical domains have grown to produce large amount
of essential process information unobtainable by other means.
For healthcare reporting systems there must be incentives to
promote voluntary reporting completely, confidently, and
objectively. Reporting should be the right, easy, and safe
policy for healthcare professionals.”
—Paul Barach and Steve Small, “Reporting and Preventing Medical
Mishaps: Lessons from Non-Medical Near Miss Reporting Systems,”
British Medical Journal, 2000.
Speakers:
Paul Barach, M.D., M.P.H.
Anesthesiology and Critical Care, Pritzker School of Medicine,
University of Chicago
Presentation: Lessons Learned from the Patient Safety Movement:
The End of the Beginning
Edward A. Dauer, LL.B.,
M.P.H.
University of Denver School of Law
Presentation: Legal Responses to Medical Error: Lessons from the
Emerging Field of Therapeutic Jurisprudence
Ron Feinstein., D.M.D., M.D.,
FACS
Kaiser Permanente, Los Angeles
Presentation: The Patient First: A Surgeon’s Perspective on a
Service Line’s Approach to Both Efficiency and Safety
Harold Kaplan, M.D.
Columbia University College of Physicians and Surgeons
Presentation: Benefiting from the “Gift of Failure”: Essentials
of an Event Reporting System
Marshall Kapp, J.D., M.P.H.
Office of Geriatrics and Gerontology, Wright State University
School of Medicine
Presentation: Resident Safety and Medical Errors in Nursing
Homes: Reporting and Disclosure in a Culture of Mutual Distrust
Bryan A. Liang, M.D., Ph.D.,
J.D
Southern Illinois University School of Law and School of
Medicine
Presentation: Not Just Marketing: Using a Medical Error
Disclosure System to Promote Quality
William Rutherford, M.D.
Flight Standards and Training, United Airlines
Presentation: CRM, the Aviation Model of an Error-Tolerant
System
Stephen D. Small, M.D.
AHRG Developing Center for Research and Evaluation in Patient
Safety
University of Chicago
Presentation: Improving Healthcare Organizational Reliability: A
Model for Voluntary, State Level Confidential Learning Systems
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