Table 1

 The 10 highest-cited patient safety papers

Principal authorYearWeb of Science Citations 16 August 2005Average citations per yearSummary
ADEs, adverse drug events; CDSSs, computer-based decision support systems; POE, physician computerised orderentry.
Brennan TA199189064The results of the Harvard Medical Practice Study I. A retrospective record review, showing that 3.7% of patients in New York hospitals experience disabling injuries as a result of medical treatment and that 28% of these are caused by negligence, in the sense that they were probably preventable.
Leape LL199171551The second part of the Harvard Medical Practice Study Results, elaborated on the results of the first part, including the procedures resulting in adverse events, whether related to an operation—for example, a wound infection, or not, as in cases with diagnostic mishaps. This paper stated that patients ⩾65 years old experience adverse events twice as frequently as those <65.
Bates DW199563063A study of the incidence of ADEs and potential ADEs in 4031 patients who spent a total of 21 412 days in hospitals. 247 ADEs (28% preventable) and 194 potential ADEs (incidents with potential for injury related to a drug, 43% of which were prevented before drug administration) were identified.
Leape LL199456351A study of the causes of errors and the ways in which they may be prevented. Leape examines various different theories of cognition and the physiological and psychological factors that may affect performance. He suggests that the current “blame culture” in the medical system is destructive in that it means that errors are not reported and so cannot be learnt from.
Fischhoff B197555919A study of the effect of outcome knowledge on judgement under uncertainty. Patients were told of an unfamiliar historical event such as a war in India and given four possible outcomes. They were then asked to say how likely they thought each outcome was to have occurred. Some of the patients were told that one of the outcomes was “true”, and their responses to the likelihood of each of the outcomes were compared with the control group. The study showed that when people think they know of the outcome of an event, they are more likely to judge it as being “true”, but they are unaware of the effect that this outcome knowledge has on their perceptions.
McDonald CJ197639814One of the earliest studies into the efficacy of protocol-based computer reminding systems. The results suggested that they are useful, but especially if they reflect a doctor’s actual decision-making logic.
Bates DW199836452A classic study of the effect of POE and team interventions on the incidence of ADEs showed that the rate of non-intercepted serious medication errors was reduced by 55% by these interventions.
Wilson RM199532533The Quality in Australian Health Care Study, based on the Harvard Medical Practice Study, reviewed 14 179 patient records and found 2353 adverse events (a rate of 16.6%). Over half of the adverse events were judged to have a high preventability rating.
Hunt DL199831645A systematic review of the effectiveness of CDSSs. 68 studies that looked at CDSSs were selected and evaluated and the results of the studies were recorded. 15 of the studies looked at drug-dosing systems, with six finding them to be effective, two ineffective and the remaining seven concerned with warfarin dosing and giving inconsistent results. Five studies assessed CDSSs and only one found it effective. Of the 19 preventative care CDSSs, 14 provided a benefit. 29 studies looked at the role of CDSSs in other aspects of medical care and 23 were beneficial. Overall, 65% of the studies found that the CDSSs were effective.
Reason J200020140Reason discusses the causes of errors, which are either human or system based. He examines approaches to error in high-reliability organisations such as Air Traffic Control and the nuclear power industry. He advocates a shift towards a systems-based approach to error in medicine.