The silence of the unblown whistle: the Nevada hepatitis C public health crisis.

Elizabeth Leary; Donna Diers

Commentary

The silence of the unblown whistle: the Nevada hepatitis C public health crisis.

April 3, 2013

Leary E, Diers D. Yale J Biol Med. 2013;86(1):79-87.

View more articles from the same authors.

This commentary describes unsafe practices that resulted in the spread of an infectious disease and highlights how poor whistleblower protection prevented employees from speaking up.

Free full text

PubMed citation

Related Resources From the Same Author(s)

Is "first do no harm" a lost concept in medical education?

October 4, 2006

Creating safe spaces in organizations to talk about safety.

March 6, 2005

Targeting the fear of safety reporting on a unit level.

March 20, 2019

Residency program fills medication safety void.

December 14, 2005

Advocate Health Care: a systemwide approach to quality and safety.

March 27, 2005

Family involvement, patient safety and suicide prevention in mental healthcare: ethnographic study.

April 19, 2023

Inpatients notes: sensemaking—fostering a shared understanding in clinical teams.

August 30, 2017

Concept analysis: wrong-site surgery.

June 17, 2015

Speaking up to reduce noise in the OR.

July 22, 2015

Counting for patient safety.

September 6, 2006

Lessons learned: basic evidence-based advice for preventing medication errors in children.

October 19, 2005

Views of children, parents, and health-care providers on pediatric disclosure of medical errors.

April 11, 2018

Mitigating patient and consumer safety risks when using conversational assistants for medical information: exploratory mixed methods experiment.

December 15, 2021

Interruptions and geographic challenges to nurses' cognitive workload.

July 1, 2009

Nursing surveillance: a concept analysis

May 18, 2022

Effect of surgical safety checklists on pediatric surgical complications in Ontario.

April 6, 2016

Nurses' perceptions of causes of medication errors and barriers to reporting.

December 20, 2006

Communication discrepancies between physicians and hospitalized patients.

August 18, 2010

Crushing or splitting medications: unrecognized hazards.

January 25, 2012

Implementing AORN recommended practices for laser safety.

May 23, 2012

Racial disparities in child abuse medicine.

November 3, 2021

Iatrogenesis in the context of residential dementia care: a concept analysis.

August 3, 2022

The role of information technology in healthcare communications, efficiency, and patient safety: application and results.

April 25, 2007

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

January 18, 2006

Root cause analyses of suicides of mental health clients.

November 18, 2015

Use of unit-based interventions to improve the quality of care for hospitalized medical patients: a national survey.

August 2, 2017

Structural empowerment and patient safety culture among registered nurses working in adult critical care units.

November 3, 2010

Education and reporting of diagnostic errors among physicians in internal medicine training programs.

September 19, 2018

Patient safety and suicide prevention in mental health services: time for a new paradigm?

February 19, 2020

High-alert medications in the pediatric intensive care unit.

January 7, 2009

Hospital quality and patient safety competencies: development, description, and recommendations for use.

January 30, 2005

The JCAHO patient safety event taxonomy: a standardized terminology and classification schema for near misses and adverse events.

March 6, 2005

Targeted communication intervention using nursing crew resource management principles.

March 25, 2015

Field test of the World Health Organization Multi-professional Patient Safety Curriculum Guide.

October 14, 2015

Evaluating a new rapid response team: NP-led versus intensivist-led comparisons.

February 29, 2012

Moving beyond implicit bias in antiracist academic medicine initiatives.

September 7, 2022

"Everybody makes mistakes": children's views on medical errors and disclosure.

January 29, 2020

Sustaining innovations in complex health care environments: a multiple-case study of rapid response teams.

April 15, 2020

Assessment of teamwork during structured interdisciplinary rounds on medical units.

October 31, 2012

Contextual factors influencing the implementation of a multifaceted intervention to improve teamwork and quality for hospitalized patients: a multi-site qualitative comparative case study.

November 1, 2023

Diagnostic errors in primary care: lessons learned.

February 22, 2012

Necessity for a pathway for "high-alert" patients.

May 23, 2018

Improving teamwork: impact of structured interdisciplinary rounds on a medical teaching unit.

April 28, 2010

"Canary measures" among the AHRQ Patient Safety Indicators.

September 9, 2009

Multiple patient safety events within a single hospitalization: a national profile in US hospitals.

April 25, 2012

I-PSI: short- and long-term efficacy of a comprehensive initiative to promote patient safety event reporting by trainees.

August 25, 2021

Training in safe opioid prescribing and treatment of opioid use disorder in internal medicine residencies: a national survey of program directors.

October 12, 2022

Exploring the factors that drive clinical negligence claims: stated preferences of those who have experienced unintended harm.

February 21, 2024

The relationship between high-reliability practice and hospital-acquired conditions among the Solutions for Patient Safety Collaborative.

October 20, 2021

Patient safety problems in adolescent medical care.

January 18, 2006

Teamwork on inpatient medical units: assessing attitudes and barriers.

May 5, 2010

The effect of hospitalist discontinuity on adverse events.

March 25, 2015

Establishing an international baseline for medication safety in oncology: findings from the 2012 ISMP International Medication Safety Self Assessment for Oncology.

December 3, 2014

Occupational therapy utilization in veterans with dementia: a retrospective review of root cause analyses of falls leading to adverse events.

April 6, 2022

Performance-based payment incentives increase burden and blame for hospital nurses.

February 16, 2011

Effect of patient-centred bedside rounds on hospitalised patients' decision control, activation and satisfaction with care.

January 6, 2016

Interdisciplinary teamwork in hospitals: a review and practical recommendations for improvement.

November 16, 2011

Patient and consumer safety risks when using conversational assistants for medical information: an observational study of Siri, Alexa, and Google Assistant.

September 19, 2018

Potential costs and consequences associated with medication error at hospital discharge: an expert judgement study.

May 10, 2023

Interventions to improve hand hygiene compliance in patient care.

September 1, 2017

Nurse–physician teamwork in the emergency department: impact on perceptions of job environment, autonomy, and control over practice.

May 8, 2013

An educational intervention to increase "speaking-up" behaviors in nurses and improve patient safety.

January 11, 2012

Preoperative communication between anesthesia, surgery, and primary care providers for older surgical patients.

March 6, 2024

Medication administration variances before and after implementation of computerized physician order entry in a neonatal intensive care unit.

January 16, 2008

Health outcomes associated with potentially inappropriate medication use in older adults.

April 2, 2008

Adverse events and preventable adverse events in children.

March 6, 2005

Medication communication: a concept analysis.

March 31, 2010

Effects of interdisciplinary collaboration in hospitals on medication errors: an integrative review.

February 28, 2018

The WakeWings journey: creating a patient safety program.

July 13, 2016

Communication relating to family members' involvement and understandings about patients' medication management in hospital.

January 6, 2016

Detection of medication-related problems in hospital practice: a review.

October 2, 2013

From the school of nursing quality and safety officer: nursing students' use of safety reporting tools and their perception of safety issues in clinical settings.

May 1, 2013

Medical devices and patient safety.

August 22, 2012

Communication in the perioperative setting.

September 14, 2011

Nursing student medication errors: a snapshot view from a school of nursing's quality and safety officer.

February 26, 2014

Notes on healing after a missed diagnosis.

October 19, 2022

Safety events impacting hospitalized patients following motor vehicle crashes: a qualitative study of reports from Pennsylvania hospitals.

October 6, 2021

Hospitalized patients' understanding of their plan of care.

January 27, 2010

Application of failure mode and effect analysis in a radiology department.

November 10, 2010

Defining attributes of patient safety through a concept analysis.

July 15, 2015

The courage to speak out: a study describing nurses' attitudes to report unsafe practices in patient care.

August 14, 2019

Prescription errors and outcomes related to inconsistent information transmitted through computerized order entry: a prospective study.

June 3, 2009

Ambulatory care adverse events and preventable adverse events leading to a hospital admission.

April 18, 2007

Safe medication prescribing: training and experience of medical students and housestaff at a large teaching hospital.

July 13, 2005

No excuses: the reality that demands action.

September 1, 2005

Increasing patient safety and surgical team communication by using a count/time out board.

October 20, 2010

Application of human error theory in case analysis of wrong procedures.

June 16, 2010

Surgical count practice variability and the potential for retained surgical items.

February 22, 2012

Strategies for improving patient safety: linking task type to error type.

February 22, 2012

A spotlight on strategies for increasing safety reporting in nursing education.

January 4, 2012

Trends in health information technology safety: from technology-induced errors to current approaches for ensuring technology safety.

August 7, 2013

Quality, patient safety, and the cardiac surgical team.

June 19, 2013

Blame: what does it look like?

November 14, 2018

Recognizing the ordinary as extraordinary: insight into the "way we work" to improve patient safety outcomes.

August 2, 2017

Quality and safety education for nurses: a nursing leadership skills exercise.

June 4, 2014

Recognizing and managing errors of cognitive underspecification.

March 19, 2014

Patient safety and technology.

May 20, 2009

The second victim: a contested term?

December 1, 2021

Unreported errors in the intensive care unit: a case study of the way we work.

November 14, 2007

Pediatric medical errors part 1: the case. A pediatric drug overdose case.

March 6, 2005

Related Resources

Appropriate use of medical interpreters in the breast imaging clinic.

February 28, 2024

National Healthcare Quality and Disparities Reports.

January 9, 2024

Drugmakers are abandoning cheap generics, and now US cancer patients can’t get meds.

July 5, 2023

Inside the preventable deaths that happened within a prominent transplant center.

June 28, 2023

Hospitals in two states denied an abortion to a miscarrying patient. Investigators say they broke federal law.

May 31, 2023

Structural racism in behavioral health presentation and management.

May 17, 2023

Lessons from the Covid War: An Investigative Report.

May 10, 2023

An infrastructure to provide safer, higher quality, and more equitable telehealth.

March 1, 2023

During in-flight emergencies, sometimes airlines’ medical kits fall short.

January 18, 2023

Understanding how the design and implementation of online consultations affect primary care quality: systematic review of evidence with recommendations for designers, providers, and researchers.

November 30, 2022

Medical error and vulnerable communities.

November 16, 2022

A new category of "never events"-ending harmful hospital policies.

November 9, 2022

The Lancet Commission on lessons for the future from the COVID-19 pandemic.

October 12, 2022

COVID-19 in Nursing Homes: CMS Needs to Continue to Strengthen Oversight of Infection Prevention and Control.

October 12, 2022

Physicians and cognitive decline: a challenge for state medical boards.

September 7, 2022

Health care quality and safety in a correctional system: creating goals and performance measures for improvement.

August 17, 2022

Clinic design for safety during the pandemic: safety or teamwork, can we only pick one?

May 11, 2022

Nearly all thirty most frequently used emergency department drugs experienced shortages from 2006-2019.

April 27, 2022

COVID-19 Focused Inspection Initiative in Healthcare.

March 23, 2022

A widow’s mission to change NC dental sedation rules.

March 23, 2022

Patient Safety Primers

Coronavirus Disease 2019 (COVID-19) and Safety of Older Adults Residing in Nursing Homes

February 24, 2022

The abrupt expansion of ambulatory telemedicine: implications for patient safety.

February 9, 2022

Hospital at Home: setting a regulatory course to ensure safe, high-quality care.

February 2, 2022

Impact of state nurse practitioner regulations on potentially inappropriate medication prescribing between physicians and nurse practitioners: a national study in the United States.

December 8, 2021

Association of dose tapering with overdose or mental health crisis among patients prescribed long-term opioids.

August 25, 2021

Missing diagnoses during the COVID-19 pandemic: a year in review.

June 23, 2021

State medical board regulation of compounding in physician offices.

June 9, 2021

Recognizing the importance of whistleblowers in healthcare.

April 14, 2021

Addressing systemic racism in nursing homes: a time for action.

April 14, 2021

Medicare cuts payment to 774 hospitals over patient complications.

March 3, 2021

See More About The Topic

Ambulatory Clinic or Office

Health Care Executives and Administrators

Policy Makers

Internal Medicine

Public Health

The silence of the unblown whistle: the Nevada hepatitis C public health crisis.

Coronavirus Disease 2019 (COVID-19) and Safety of Older Adults Residing in Nursing Homes

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

The silence of the unblown whistle: the Nevada hepatitis C public health crisis.

Coronavirus Disease 2019 (COVID-19) and Safety of Older Adults Residing in Nursing Homes

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