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Semin Med Pract 
2001 Jun ;4(2):5-16
When a good care plan goes wrong
Yetman RJ

The mainstream press and medical literature have devoted considerable attention to patient safety since the recent Institute of Medicine (IOM) report, To Err is Human, exposed the magnitude of medical errors that occur in the course of patient care. Although some medical errors result in no harm to patients, others can have devastating consequences for the patient and the entire medical team involved, and all are associated with avoidable costs to the health care system. In this article, the author describes what the IOM refers to as misuse quality problems (preventable complications in appropriate care plans), with a focus on how and why these problems occur. A basic framework for understanding current internal and external efforts to reduce misuse quality problems also is provided.

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