Understanding and Responding to Adverse Events

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Abstract
This article describes a method of investigating and learning from adverse events. Careful investigation and systems analysis can identify the factors that set the stage for a medical error. The author argues that the process of understanding adverse events leads to improvements in care and reductions in errors and that insensitive and inadequate handling of an incident can result in additional harm to patients and families. He outlines practical strategies to minimize the trauma resulting from adverse events.