Top 10 patient safety issues: what more can we do?

Victoria M. Steelman; Paula R. Graling

Commentary

Top 10 patient safety issues: what more can we do?

June 19, 2013

Steelman VM, Graling PR. AORN J. 2013;97(6):679-98, quiz 699-701.

View more articles from the same authors.

This commentary reveals nurses' concerns about patient safety along with interventions to address them.

PubMed citation

Available at

Related Resources From the Same Author(s)

Priority patient safety issues identified by perioperative nurses.

May 8, 2013

Learning and mindfulness: improving perioperative patient safety.

April 19, 2017

Accountability in nursing practice: why it is important for patient safety.

December 10, 2014

Designing a safer process to prevent retained surgical sponges: a healthcare failure mode and effect analysis.

August 17, 2011

Unintentionally retained guidewires: a descriptive study of 73 sentinel events.

March 20, 2019

Unintentionally retained foreign objects: a descriptive study of 308 sentinel events and contributing factors.

November 28, 2018

The hidden costs of reconciling surgical sponge counts.

November 11, 2015

Surgical specimen management: a descriptive study of 648 adverse events and near misses.

October 5, 2016

Judging whether a patient is actually improving: more pitfalls from the science of human perception.

June 6, 2012

Organisational paradoxes in speaking up for safety: implications for the interprofessional field.

December 13, 2017

The impact of organisational and individual factors on team communication in surgery: a qualitative study.

December 16, 2009

The contribution of prescription chart design and familiarity to prescribing error: a prospective, randomised, cross-over study.

October 9, 2013

Exploring error in team-based acute care scenarios: an observational study from the United Kingdom.

June 6, 2012

Understanding the behaviour of newly qualified doctors in acute care contexts.

November 2, 2011

Systematic review of clinical debriefing tools: attributes and evidence for use.

April 19, 2023

Implementation, CPOE, and medication errors.

June 8, 2005

Surgical patient safety outcomes in critical access hospitals: how do they compare?

April 6, 2016

For-profit long-term care homes and the risk of COVID-19 outbreaks and resident deaths.

August 19, 2020

Patient safety and professional discourses: implications for interprofessionalism.

May 14, 2014

How do hospitalized patients feel about resident work hours, fatigue, and discontinuity of care?

June 4, 2008

Safety on the ground: using critical incident technique to explore the factors influencing medical registrars' provision of safe care.

March 20, 2024

Serious hazards of transfusion (SHOT) haemovigilance and progress is improving transfusion safety.

November 20, 2013

Drug shortages and clinicians: no time for complacency.

October 3, 2012

Relationship between psychological safety and reporting nonadherence to a safety checklist.

April 18, 2018

Changes in prescription and over-the-counter medication and dietary supplement use among older adults in the United States, 2005 vs 2011.

May 4, 2016

What happened to my patient? An educational intervention to facilitate postdischarge patient follow-up.

November 22, 2017

Do crowdsourced hospital ratings coincide with Hospital Compare measures of clinical and nonclinical quality?

September 12, 2018

Near miss audit in obstetrics.

May 2, 2007

Improving standardization of paging communication using quality improvement methodology.

April 10, 2019

Unintentional discontinuation of chronic medications for seniors in nursing homes: evaluation of a national medication reconciliation accreditation requirement using a population-based cohort study.

July 8, 2015

Choosing your words carefully: how physicians would disclose harmful medical errors to patients.

August 16, 2006

How improving practice relationships among clinicians and nonclinicians can improve quality in primary care.

September 9, 2009

A practical approach to measure the quality of handwritten medication orders: a tool for improvement.

May 24, 2006

Safe prescribing: an educational intervention for medical students.

July 19, 2006

Variability in antibiotic use across nursing homes and the risk of antibiotic-related adverse outcomes for individual residents.

July 29, 2015

Afraid in the hospital: parental concern for errors during a child's hospitalization.

August 19, 2009

A systematic review of the effectiveness, compliance, and critical factors for implementation of safety checklists in surgery.

October 17, 2012

Meta-analyses of the effects of standardized handoff protocols on patient, provider, and organizational outcomes.

February 22, 2017

Medication reconciliation to facilitate transitions of care after hospitalization.

June 10, 2015

The Shift Coupon: an innovative method to monitor adverse events.

January 18, 2006

Teaching quality improvement.

September 22, 2010

Communicating critical test results: safe practice recommendations.

April 3, 2005

PSYCH: a mnemonic to help psychiatric residents decrease patient handoff communication errors.

June 29, 2016

The Team Climate Inventory: application in hospital teams and methodological considerations.

August 27, 2008

Development of a professionalism committee approach to address unprofessional medical staff behavior at an academic medical center.

April 9, 2014

Success of a resident-led safety council: a model for satisfying CLER Pathways to Excellence patient safety goals.

October 9, 2019

The urgent need to improve health care quality. Institute of Medicine National Roundtable on Health Care Quality.

March 27, 2005

A multidisciplinary approach to adverse drug events in pediatric trauma patients in an adult trauma center.

July 15, 2009

Pain as the neglected patient safety concern: five years on.

May 18, 2016

Making patients safer: nurses' responses to patient safety alerts.

September 24, 2008

Reducing medication prescribing errors in a teaching hospital.

August 27, 2008

Hospitalized patients' attitudes about and participation in error prevention.

May 17, 2006

New solutions to reduce wrong route medication errors.

December 13, 2017

Exploring nurses' attitudes, skills, and beliefs of medication safety practices.

August 24, 2022

Comparison and interpretation of urinalysis performed by a nephrologist versus a hospital-based clinical laboratory.

January 18, 2006

The nature of surgical error: a cautionary tale and a call to reason.

August 3, 2005

Interventions to support nurses as second victims of patient safety incidents: a qualitative study of nurse managers' perceptions.

February 7, 2024

Evaluation of patient and family outpatient complaints as a strategy to prioritize efforts to improve cancer care delivery.

October 4, 2017

The impact of post-fall huddles on repeat fall rates and perceptions of safety culture: a quasi-experimental evaluation of a patient safety demonstration project

October 16, 2019

Lessons learned from a systems approach to engaging patients and families in patient safety transformation.

February 12, 2020

Quality improvement for patient safety: project-level versus program-level learning.

February 22, 2012

We need to talk: an observational study of the impact of electronic medical record implementation on hospital communication.

March 19, 2014

Differences in safety report event types submitted by graduate medical education trainees compared with other healthcare team members.

December 8, 2021

A new professionalism? Surgical residents, duty hours restrictions, and shift transitions.

November 17, 2010

Nurses' communication of safety events to nursing home residents and families.

November 15, 2017

Lost opportunities: how physicians communicate about medical errors.

January 23, 2008

Implementing a team-based daily goals sheet in a non-ICU setting.

July 1, 2009

Medical error disclosure among pediatricians: choosing carefully what we might say to parents.

October 15, 2008

Good Practice Guides on Medication Errors: Part 1 and Part 2.

April 13, 2016

Implementing a safer and more reliable system to monitor test results at a teaching university-affiliated facility in a family medicine group: a quality improvement process report.

November 1, 2023

Effect of computerized provider order entry with clinical decision support on adverse drug events in the long-term care setting.

February 11, 2009

Using a modified A3 lean framework to identify ways to increase students' reporting of mistreatment behaviors.

May 9, 2018

Medication errors in pediatric inpatients: prevalence and results of a prevention program.

September 17, 2008

The pharmacist-physician relationship in the detection of ambulatory medication errors.

January 31, 2006

Feasibility of patient-reported diagnostic errors following emergency department discharge: a pilot study.

October 28, 2020

Communication of incidental imaging findings on inpatient discharge summaries after implementation of electronic health record notification system.

April 3, 2024

Implementing a national strategy for patient safety: lessons from the National Health Service in England.

April 21, 2005

Doing right by our patients when things go wrong in the ambulatory setting.

February 12, 2014

US and Canadian physicians' attitudes and experiences regarding disclosing errors to patients.

August 16, 2006

Effectiveness of continuous or intermittent vital signs monitoring in preventing adverse events on general wards: a systematic review and meta-analysis.

October 12, 2016

Use of medical emergency team responses to reduce hospital cardiopulmonary arrests.

March 27, 2005

Use of medical emergency team (MET) responses to detect medical errors.

March 6, 2005

Correlation between hospital finances and quality and safety of patient care.

September 4, 2019

Computerized clinical decision support during medication ordering for long-term care residents with renal insufficiency.

July 22, 2009

Impact of computerized physician order entry alerts on prescribing in older patients.

March 25, 2015

A family-centered rounds checklist, family engagement, and patient safety: a randomized trial.

May 31, 2017

Patient safety event reporting in critical care: a study of three intensive care units.

March 21, 2007

Implementing a commercial rule base as a medication order safety net.

August 31, 2005

Advancing nursing home quality through quality improvement itself.

January 20, 2010

The ongoing quality improvement journey: next stop, high reliability.

April 20, 2011

Attending physician work hours: ethical considerations and the last doctor standing.

July 29, 2009

The rising frequency of IT blackouts indicates the increasing relevance of IT emergency concepts to ensure patient safety.

December 7, 2016

High-reliability health care: getting there from here.

October 2, 2013

ASHP guidelines on managing drug product shortages.

August 15, 2018

How willing are patients to question healthcare staff on issues related to the quality and safety of their healthcare? An exploratory study.

April 16, 2008

Medication therapy management programs: forming a new cornerstone for quality and safety in Medicare.

August 2, 2006

Organizational learning: health care leaders need to design structures and processes that enhance collective learning.

March 27, 2005

Improving the quality of health care: who will lead?

March 6, 2005

Patients' concerns about medical errors during hospitalization.

January 3, 2007

A new safety event reporting system improves physician reporting in the surgical intensive care unit.

June 14, 2006

Related Resources

Fire safety in the operating room.

October 1, 2023

The things we carry: the scope and impact of second victim syndrome.

August 2, 2023

Improving handoffs in the perioperative environment: a conceptual framework of key theories, system factors, methods, and core interventions to ensure success.

July 19, 2023

Preventing surgical site infections: implementing strategies throughout the perioperative continuum.

July 19, 2023

Understanding the root cause analysis process to increase safety event reporting.

July 5, 2023

Proactive patient safety: focusing on what goes right in the perioperative environment.

May 24, 2023

Normalization of deviance is contrary to the principles of high reliability.

April 12, 2023

WebM&M Cases

Respiratory Distress after Neck Surgery: Two Cases of Postoperative Cervical Hematoma.

February 1, 2023

Errors in surgery: a case control study.

December 14, 2022

Factors causing variation in World Health Organization surgical safety checklist effectiveness-a rapid scoping review.

December 14, 2022

Guidelines in Practice: prevention of unintentionally retained surgical items.

December 7, 2022

Patients' experience of patient safety information and participation in care during a hospital stay.

November 16, 2022

Eliminating Unintentionally Retained Surgical Items - Special Report.

September 21, 2022

Potentially inappropriate medication administration is associated with adverse postoperative outcomes in older surgical patients: a retrospective cohort study.

September 14, 2022

Preventing retained surgical items.

August 3, 2022

AORN Position Statement on Patient Safety.

May 1, 2022

The evolution of the Anesthesia Patient Safety Movement in America: lessons learned and considerations to promote further improvement in patient safety.

January 26, 2022

Influence of perioperative handoffs on complications and outcomes.

November 17, 2021

Decreased incidence of cesarean surgical site infection rate with hospital-wide perioperative bundle.

September 29, 2021

Society for Maternal-Fetal Medicine Special Statement: Surgical safety checklists for cesarean delivery.

September 22, 2021

Using performance improvement to enhance time-out compliance and prevent wrong-site surgery.

August 11, 2021

FDA Safety Communication: flexible bronchoscopes and updated recommendations for reprocessing.

February 24, 2022 - February 24, 2022

Time out! Rethinking surgical safety: more than just a checklist.

April 28, 2021

Outcomes from Wake Up Safe, the pediatric anesthesia quality improvement initiative.

February 3, 2021

A comprehensive estimation of the costs of 30-day postoperative complications using actual costs from multiple, diverse hospitals.

October 14, 2020

Identifying safety hazards associated with intravenous vancomycin through the analysis of patient safety event reports.

April 15, 2020

A protocol for the safe use of hazardous drugs in the OR.

March 25, 2020

WebM&M Cases

Is that solution for IV or irrigation?: Fluid administration errors in the operating room.

March 25, 2020

Reduce the likelihood of patient harm associated with the use of anticoagulant therapy: commentary from the Anticoagulation Forum on the Updated Joint Commission NPSG.03.05.01 Elements of Performance

March 4, 2020

Reducing surgical mortality in Scotland by use of the WHO Surgical Safety Checklist.

May 8, 2019

See More About The Topic

Operating Room

Nurses

Health Care Executives and Administrators

Surgery

Medical/Surgical Nursing

Top 10 patient safety issues: what more can we do?

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Top 10 patient safety issues: what more can we do?

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site