To Err Is Human

Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (2000). To Err Is Human: Building a Safer Health System. National Academy Press.

Type

Book

Intellectual base

Review or monograph

Year

2000

Pages cited

000-98

DOI

10.17226/9728

ISBN

9780309261746

DOI registrant

National Academies Press

Link

https://doi.org/10.17226/9728

Cited from

systems_cybernetics

Cited by

2 citations across 2 artifacts.

Each citation links to the sentence it supports in the citing article.

Primes

• Swiss Cheese Model (Layered Defense with Aligning Holes)
  • Aviation's crew resource management, just-culture reporting, and stacked-defense thinking transferred to medicine, with the vocabulary of layers, holes, alignment, and latent conditions traveling intact.

    This sourceImports aviation's systems-safety, crew-resource-management, and just-culture thinking — including layered-defense and latent-condition analysis — into medicine.

Domain-specific

• Medication Error
  • The Institute of Medicine's 1999 report To Err Is Human (Kohn, Corrigan, and Donaldson) estimated that 44,000–98,000 Americans die in US hospitals each year from medical errors of all kinds, put deaths from medication errors alone at over 7,000 a year, and reoriented analysis from individual blame to system design: the question is not who made the mistake but which combination of operational conditions allowed the mistake to escape all downstream checks

    SupportedVerified against the source

    Read by an automated reader; not a human review. How support was checked

Verification

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