Scandal as a sentinel event—recognizing hidden cost–quality trade-offs. | PSNet

Provide Feedback |

Submit a Case

Register

Commentary

Scandal as a sentinel event—recognizing hidden cost–quality trade-offs.

April 6, 2016

Bloche G. N Engl J Med. 2016;374(11):1001-3.

View more articles from the same authors.

Latent factors are known to contribute to system-level failures. This commentary discusses the Mid Staffordshire NHS Foundation Trust inquiry and the Veterans Affairs health system investigation as examples of how executive expectations to meet performance targets and insufficient safety culture led to unintended consequences and system failures.

PubMed citation

Related editorial

Related Resources From the Same Author(s)

Unintended harm associated with the Hospital Readmissions Reduction Program.

January 16, 2019

Case 34-2010: a 65-year-old woman with an incorrect operation on the left hand.

November 17, 2010

A middle ground on public accountability.

March 6, 2005

Patient safety is not elective: a debate at the NPSF Patient Safety Congress.

December 3, 2014

Overarching goals: a strategy for improving healthcare quality and safety?

December 19, 2012

The cost of quality: an academic health center's annual costs for its quality and patient safety infrastructure.

July 25, 2018

Setting quality and safety priorities in a target-rich environment: an academic medical center's challenge.

August 28, 2013

Patient safety climate in hospitals: act locally on variation across units.

June 30, 2010

Relationship between performance measurement and accreditation: implications for quality of care and patient safety.

November 2, 2005

Design and evaluation of simulation scenarios for a program introducing patient safety, teamwork, safety leadership, and simulation to healthcare leaders and managers.

August 31, 2011

Cognitive bias impact on management of postoperative complications, medical error, and standard of care.

November 4, 2020

A case for safety leadership team training of hospital managers.

March 2, 2011

Remote video auditing with real-time feedback in an academic surgical suite improves safety and efficiency metrics: a cluster randomised study.

February 10, 2016

Transforming concepts in patient safety: a progress report.

August 1, 2018

Association of the Hospital Readmissions Reduction Program implementation with readmission and mortality outcomes in heart failure.

November 22, 2017

The impact of electronic medical records data sources on an adverse drug event quality measure.

March 17, 2010

Effects of CPOE on provider cognitive workload: a randomized crossover trial.

September 5, 2012

Improving patient safety in radiation oncology.

March 16, 2011

Preventable errors in organ transplantation: an emerging patient safety issue?

July 11, 2012

Using data to enhance performance and improve quality and safety in surgery.

August 30, 2017

Effective physician–nurse communication: a patient safety essential for labor and delivery.

January 30, 2005

Implementing an obstetric emergency team response system: overcoming barriers and sustaining response dose.

November 4, 2015

Functional health literacy and understanding of medications at discharge.

July 16, 2008

Preventing adverse events in cataract surgery: recommendations from a Massachusetts expert panel.

August 8, 2018

Nurses' perspectives on the intersection of safety and informed decision making in maternity care.

December 4, 2013

Errors as allies: error management training in health professions education.

January 23, 2013

Studying critical values: adverse event identification following a critical laboratory values study at the Ohio State University Medical Center.

October 17, 2007

Imperfect practice makes perfect: error management training improves transfer of learning.

April 26, 2017

The evolution of error: error management, cognitive constraints, and adaptive decision-making biases.

July 24, 2013

Automated surveillance for adverse drug events at a community hospital and an academic medical center.

May 3, 2006

Adverse events associated with procedural sedation and analgesia in a pediatric emergency department: a comparison of common parenteral drugs.

June 22, 2005

Implementing a national program to reduce catheter-associated urinary tract infection: a quality improvement collaboration of state hospital associations, academic medical centers, professional societies, and governmental agencies.

December 18, 2013

Cost of medication-related problems at a university hospital.

March 27, 2005

Associations between attending physician workload, teaching effectiveness, and patient safety.

February 3, 2016

Confronting safety gaps across labor and delivery teams.

January 15, 2014

A multiobserver study of the effects of including point-of-care patient photographs with portable radiography: a means to detect wrong-patient errors.

October 8, 2014

Avoiding potential harm by improving appropriateness of urinary catheter use in 18 emergency departments.

July 16, 2014

Exploring perinatal shift-to-shift handover communication and process: an observational study.

May 28, 2014

Double reading in breast cancer screening: cohort evaluation in the CO-OPS trial.

August 29, 2018

Using drug knowledgebase information to distinguish between look-alike-sound-alike drugs.

June 27, 2018

Matching identifiers in electronic health records: implications for duplicate records and patient safety.

March 13, 2013

Economic outcomes associated with safety interventions by a pharmacist–adjudicated prior authorization consult service.

May 29, 2019

Effect of hospital follow-up appointment on clinical event outcomes and mortality.

July 14, 2010

Measuring hospital adverse events: assessing inter-rater reliability and trigger performance of the Global Trigger Tool.

June 30, 2010

The prevalence of wrong level surgery among spine surgeons.

January 30, 2008

Reflections on implementing a hospital-wide provider-based electronic inpatient mortality review system: lessons learnt.

November 13, 2019

Errors and omissions in hospital prescriptions: a survey of prescription writing in a hospital.

July 1, 2009

From box ticking to the black box: the evolution of operating room safety.

September 4, 2019

The vulnerabilities of computerized physician order entry systems: a qualitative study.

December 9, 2015

Intraoperative adverse events and related postoperative complications in spine surgery: implications for enhancing patient safety founded on evidence-based protocols.

June 21, 2006

The top patient safety strategies that can be encouraged for adoption now.

March 13, 2013

Information handoff and outcomes of critically ill patients transferred between hospitals.

November 2, 2016

Outpatient CPOE orders discontinued due to 'erroneous entry': prospective survey of prescribers' explanations for errors.

August 16, 2017

Predictors of medication errors among elderly hospital patients.

March 19, 2008

Evaluation of harm associated with high dose-range clinical decision support overrides in the intensive care unit.

January 23, 2019

Fundamental Use of Surgical Energy (FUSE): an essential educational program for operating room safety.

April 5, 2017

Adverse drug events in surgical patients: an observational multicentre study.

November 6, 2013

Adverse drug event detection in pediatric oncology and hematology patients: using medication triggers to identify patient harm in a specialized pediatric patient population.

May 14, 2014

Process of care failures in breast cancer diagnosis.

May 13, 2009

Advancing the science of patient safety.

May 25, 2011

Implementation of bar-code medication administration to reduce patient harm.

February 20, 2019

Prospective evaluation of medication-related clinical decision support over-rides in the intensive care unit.

February 28, 2018

Evaluating implementation of a rapid response team: considering alternative outcome measures.

May 7, 2014

Rating recommendations for consumers about patient safety: sense, common sense, or nonsense?

April 8, 2009

Postdischarge adverse events for 1-day hospital admissions in older adults admitted from the emergency department.

April 7, 2010

Patient-specific electronic decision support reduces prescription of excessive doses.

May 26, 2010

Interdisciplinary Quality Improvement Conference: using a revised morbidity and mortality format to focus on systems-based patient safety issues in a VA hospital: design and outcomes.

November 12, 2014

Transparent and open discussion of errors does not increase malpractice risk in trauma patients.

May 10, 2006

Evaluation of medication-related clinical decision support alert overrides in the intensive care unit.

May 10, 2017

Analysis of variations in the display of drug names in computerized prescriber-order-entry systems.

May 24, 2017

How often do prescribers include indications in drug orders? Analysis of 4 million outpatient prescriptions.

July 10, 2019

The frequency of inappropriate nonformulary medication alert overrides in the inpatient setting.

April 6, 2016

One-stop diagnostic breast clinics: how often are breast cancers missed?

August 5, 2009

Recognition of adverse drug events in older hospitalized medical patients.

July 11, 2012

Computerised physician order entry-related medication errors: analysis of reported errors and vulnerability testing of current systems.

January 28, 2015

Improving cancer patient care with combined medication error reviews and morbidity and mortality conferences.

May 28, 2014

A handoff protocol from the cardiovascular operating room to cardiac ICU is associated with improvements in care beyond the immediate postoperative period.

July 17, 2013

Effect of using the same vs different order for second readings of screening mammograms on rates of breast cancer detection: a randomized clinical trial.

June 1, 2016

Screening for adverse drug events: a randomized trial of automated calls coupled with phone-based pharmacist counseling.

March 6, 2019

A cross-sectional observational study of high override rates of drug allergy alerts in inpatient and outpatient settings, and opportunities for improvement.

May 25, 2016

Classifying and predicting errors of inpatient medication reconciliation.

July 9, 2008

A program to prevent catheter-associated urinary tract infection in acute care.

June 8, 2016

Impact of adverse events on outcomes in intensive care unit patients.

July 2, 2008

Stand-alone artificial intelligence for breast cancer detection in mammography: comparison with 101 radiologists.

March 27, 2019

Incorporating medication indications into the prescribing process.

May 9, 2018

Computerized prescriber order entry–related patient safety reports: analysis of 2522 medication errors.

October 19, 2016

SIMMEON-Prep study: SIMulation of Medication Errors in ONcology: prevention of antineoplastic preparation errors.

December 17, 2014

Comparison of a prototype for indications-based prescribing with 2 commercial prescribing systems.

May 1, 2019

Medication-related clinical decision support alert overrides in inpatients.

November 15, 2017

Effect of an electronic medication reconciliation application and process redesign on potential adverse drug events: a cluster-randomized trial.

April 29, 2009

Outcomes associated with the nationwide introduction of rapid response systems in the Netherlands.

September 16, 2015

Effect of a comprehensive surgical safety system on patient outcomes.

November 24, 2010

Consensus-based recommendations for standardizing terminology and reporting adverse events for emergency department procedural sedation and analgesia in children.

May 13, 2009

An improved patient safety reporting system increases reports of disruptive behavior in the perioperative setting.

February 5, 2020

Risk factors for adverse events in emergency department procedural sedation for children.

October 25, 2017

Clinical communities at Johns Hopkins Medicine: an emerging approach to quality improvement.

September 2, 2015

The Safety and Quality of Health Care: Where are We Now?

June 7, 2006

ASPEN Safe Practices for Enteral Nutrition Therapy.

December 14, 2016

Structured override reasons for drug–drug interaction alerts in electronic health records.

May 15, 2019

Effect of a ward-based pharmacy team on preventable adverse drug events in surgical patients (SUREPILL study).

August 19, 2015

View More

Related Resources

VHA's movement for change: implementing high-reliability principles and practices.

May 31, 2023

Towards a unified model of accident causation: refining and validating the systems thinking safety tenets.

May 10, 2023

Events that inspired change: the importance of sharing what happened to stop it from happening again.

May 3, 2023

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

Improving safety by evaluating the impact of the supply chain and drug shortages on health-systems.

March 29, 2023

The e-Autopsy/e-Biopsy: a systematic chart review to increase safety and diagnostic accuracy.

October 26, 2022

Developing the Safer Dx Checklist of Ten Safety Recommendations for Health Care Organizations to address diagnostic errors.

October 12, 2022

Positive approaches to safety: learning from what we do well.

August 31, 2022

Reducing administrative harm in medicine - clinicians and administrators together.

July 6, 2022

Strategies to prevent central line-associated bloodstream infections in acute-care hospitals: 2022 Update.

June 22, 2022

A comprehensive departmental care review model: requirements, structure, and flow.

June 30, 2021

Health system leaders' role in addressing racism: time to prioritize eliminating health care disparities.

February 10, 2021

Risk factors associated with medication ordering errors.

December 16, 2020

To err Is human, unless you are a healthcare provider.

August 3, 2020

The Power to Predict: Leveraging Medical Malpractice Data to Reduce Patient Harm and Financial Loss.

June 24, 2020

The limits of current A.I. in health care: patient safety policing in hospitals.

June 17, 2020

Data-driven quality improvement, culture change, and the high reliability journey at a special hospital for people with medically complex developmental disabilities.

March 11, 2020

Harnessing the power of medical malpractice data to improve patient care.

January 8, 2020

Commissioning simulations to test new healthcare facilities: a proactive and innovative approach to healthcare system safety.

September 11, 2019

In-hospital sequelae of injurious falls in 24 medical/surgical units in four hospitals in the United States.

March 13, 2019

A decade of health information technology usability challenges and the path forward.

February 13, 2019

Association of adverse effects of medical treatment with mortality in the United States: a secondary analysis of the Global Burden of Diseases, Injuries, and Risk Factors study.

January 30, 2019

Cranky comments: detecting clinical decision support malfunctions through free-text override reasons.

January 16, 2019

Active-shooter response at a health care facility.

September 19, 2018

A multi-stakeholder consensus-driven research agenda for better understanding and supporting the emotional impact of harmful events on patients and families.

July 11, 2018

A piece of my mind. The art of constructive worrying.

June 20, 2018

Disruptive physician behavior: the importance of recognition and intervention and its impact on patient safety.

May 16, 2018

Matt's story: learning from heartbreak.

May 9, 2018

A framework for operationalizing risk: a practical approach to patient safety.

May 2, 2018

Latent risk assessment tool for health care leaders.

April 25, 2018

View More

See More About The Topic

Health Care Executives and Administrators

To sign up for updates or to access your subscriber preferences, please enter your email address below.

5600 Fishers Lane
Rockville, MD 20857
Telephone: (301) 427-1364