Editor’s Notebook: Learning by Definition

Careful use of terminology is essential in patient safety literature. Lucian Leape (1994) takes great care to define terms in his foundational article, “Error in Medicine.” Using the construct originated by James Reason, he defines error as “an unintended act (either of omission or commission) or one that does not achieve its intended outcome” (p. 1851).

Read More »

News – Nearly 74 Years After His Death, a Headstone Memorializes Ernest Amory Codman Boston surgeon is remembered for his visionary work in promoting medical outcomes.

To recognize the contributions of Ernest Amory Codman, MD, FACS (1869-1940), to American surgery and to patient care as a whole, a memorial headstone has been placed at his previously unmarked gravesite in the historic Mount Auburn Cemetery in Cambridge, Massachusetts. 

Read More »

Medical Devices: Who Needs to Read Device Instructions?

Essentially all medical devices used in hospitals come with a user instruction manual, commonly called Instructions for Use (IFU) or Directions for Use. Typically an IFU includes basic, operational “how to” information as well as pages of warnings, cautions, and other general or device-specific information beyond simply how to operate the device. 

Read More »

Misidentification of Alphanumeric Symbols

The English language uses the Latin alphabet with 26 letters and a numeric system with 10 numerals. These alphanumeric symbols (letters and numerals) work well most of the time when used to communicate information. However, problems may arise during written or electronic communication because of similarities in appearance of the alphanumeric symbols we use.

Read More »