One Pagers | Mar 01, 2001
Susan Dovey, MD, MPH; Larry Green, MD; Ed Fryer, PhD; Robert Phillips, MD, MSPH
Current thinking about threats to patient safety caused by medical errors is often focused in hospital on the immediate consequences of mistakes that affect specific aspects of care, such as testing procedures or medications. Some mistakes, however, become apparent distant from where they were committed and only after a lapse in time. The model of a toxic cascade organizes an approach to making U.S. health care safer for patients by locating upstream sources and downstream consequences of errors within a comprehensive, multilevel scheme.
A Toxic Cascade conceptualizes four levels of threats to patient safety. This model's application is not limited to any particular health care setting. Each part of the cascade occurs in different ways in all parts of the health care system. The cascade can evolve entirely within a single health care location or cut across organizational boundaries.
From trickles to torrents, toxic cascades likely exist in every health care setting. The comprehensive safety effort that patients deserve will discover the consequence and source of errors, incorporating all locations of care.
The information and opinions contained in research from the Graham Center do not necessarily reflect the views or the policy of the AAFP.
Published in American Family Physician, Mar 1, 2001. Am Fam Physician. 2001;63:847. This series is coordinated by Sumi Sexton, MD, AFP Associate Medical Editor.