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1 - 20 of 398

Loller T. Associated PressMarch 30, 2022.

Reporting medical errors, learning from them, and improving systems is a cornerstone of improving patient safety. A just culture centers on moving from blaming individuals for medical errors towards a systems-based approach to learning what went on, in order to prevent similar errors in the future. The recent conviction of a nurse involved in the death of a patient has raised concerns that clinicians may not disclose medical errors out of fear of criminal prosecution and conviction.

Blythe A. NC Health News. March 10, 2022

Patient harm in dentistry is receiving increased attention and scrutiny. This story covers a medication incident and the lack of safety support that contributed to the death of a patient receiving oral surgery. It discusses the response of the patient’s family and their work to change regulations for dental sedation.

ISMP Medication Safety Alert! Acute care edition. February 24, 2022; 27(4):1-5; March 10, 2022; 27(5):1-5.

Disrespect for co-workers, peers, and patients degrades safety in the care environment. Part I of this article series summarizes results from a 2021 survey as the latest installment of a long-standing examination of the prevalence of disrespectful behaviors. The results found that poor behaviors are common, a wide array of  unprofessional behaviors are encountered in the workplace, and how they affect safety. Part II shares strategies to decrease the presence and impact of disrespectful behaviors in health care which include creation of confidential reporting systems and support structures.

Quick Safety. February 14, 2022;(64):1-3.

Complete, appropriate reprocessing and sterilization of reusable medical instruments and devices is vital for infection prevention. This newsletter article shares actions to improve infection prevention, including standardized examination processes, infection preventionist involvement, and training focused on the safety impacts of incomplete processing and inappropriate reuse of single use items.

Rau J. Kaiser Health News. February 8, 2022. 

Rating systems face challenges to accurately represent the safety and quality of patient care. This article discusses inconsistent results between national rating systems and those organizations penalized by the Hospital-Acquired Condition Reduction Program though reduction of Medicare payments for hospitals recording certain adverse events.

ISMP Medication Safety Alert! Acute care edition. October 21, 2021;26(21):1-3.

Shortcuts in automated data entry behaviors have potential to result in errors. This article discusses search term length requirements for automated dispensing cabinets and the importance of doing a proactive failure analysis prior to implementing any system conditions to minimize unintended consequences of the rules that could detract from safety.

Zipp R. Medical Tech Dive. October 18, 2021.

This article highlights systems influences that detract from the effectiveness of current methods of reporting recalled unsafe medical devices and raising awareness of recalls for clinicians, patients and families. Challenges highlighted include the use of paper-based notification systems and data reporting delays.

ISMP Medication Safety Alert! Acute care edition. September 9, 2021;26(18);1-5.

Disrespectful behavior is a persistent contributor to failures in medical care. This article summarizes influences that enable the acceptance and perpetuation of unprofessional behaviors and calls for data to assess its presence and impact in health care environments. The deadline for survey participation is now closed.

Ellis NT, Broaddus A. CNN. August 25, 2021. 

Maternal safety is an ongoing challenge worldwide. This news feature examines how the COVID pandemic has revealed disparities and implicit biases that impact the maternal care of black women. The stories shared highlight experiences of mothers with preventable pregnancy-related complications.

ISMP Medication Safety Alert! Acute Care Edition. May 6, 2021;26(9):1-4.

Look-alike labeling is a known contributor to medication errors. This article summarizes common factors resulting in packaging and labeling concerns. Recommendations for improvement include partnerships with industry regarding the use of risk management practices to improve the accuracy of labeling prior to product launch.

Carr S. ImproveDx. March 2021:8(2) 

Effective diagnosis is enhanced through multidisciplinary team-based efforts. This newsletter article outlines opportunities inherent in expanding the role of nursing in the diagnostic process. It highlights barriers to collaboration and suggests interprofessional training as one avenue toward improvement.

Babic B, Cohen IG,  Evgeniou T, et al. Harv Bus Rev.  2021 January/February;99(1):76-84.

 This article discusses how machine learning can create unanticipated risks in the context of health care delivery. The authors summarize areas of concern healthcare leadership should explore when determining the implementation of machine learning in their organizations.