The PSNet Collection

Displaying 1 - 20 of 22 Results

Preventing medical errors: how to proceed with caution.

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Shaw G. The Hearing Journal. 2014;67.

This article provides an overview of patient safety issues in audiology such as diagnostic error and incomplete documentation. The author reviews steps individual clinicians can take to respond to errors and malpractice claims.

Physician: 'I almost killed a patient' because of an advance directive.

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Betbeze P. HealthLeaders Media. May 2, 2014.

Reporting on how misinterpretation of advance directives and living wills can detract from patient safety, this news article reveals insights from a physician who developed a checklist poster to provide decision support for clinicians and recommends standardization of the forms to reduce risks.

Delivering results.

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Landro L. Wall Street Journal. March 28, 2011.

This newspaper article discusses how combining best practices in teamwork, simulation, and communication can improve patient safety during obstetric emergencies.

Managing patient access and flow in the emergency department to improve patient safety.

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PA-PSRS Patient Saf Advis. 2010;7:123-134.

This report examines how optimizing patient flow from emergency department arrival to diagnosis can enhance quality and safety.

Patients, beware: 731 nurses reveal what to watch out for in the hospital.

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Consumer Reports. 2009 Sep;74(9):18-23.

Drawing from surveys of nurses and patients, this article offers tips on how to improve safety during a hospital stay.

Patient safety records: silent witness.

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Gould M. The Health Service Journal. 2008;September 15:22-24.

This article describes the state of general practitioner incident reporting in the United Kingdom.

Ferrari's Formula One handovers and handovers from surgery to intensive care.

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Sower VE; Duffy JA; Kohers G; ASQ; American Society for Quality.

This article describes the application of Formula One pit stop techniques to improving hand-off systems within a health care setting in the context of one British hospital's research on teamwork in Formula One pit crews.

Lack of standard dosing methods contributes to IV errors.

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ISMP; Institute for Safe Medication Practices.

This article discusses the myriad dosing methods that can lead to errors in administering intravenous medications and programming infusion pumps.

Five hospitals release data on inspections.

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Kowalczyk L

This article reports on the results from Joint Commission site inspections of five Boston-area hospitals.

Hospitals target risks of color wristbands.

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Landro L.

This article reports on initiatives to standardize the color designations of color-coded wristbands to avoid confusion and reduce the risk of error.

Fixing the medication reconciliation breakdown.

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Starr D; West L.

The authors describe elements and key success factors of redesigning medication delivery and administration to support medication reconciliation.

Hospitals put emphasis on collection of medication data.

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Krizner K. Managed Healthcare Executive. August 1, 2006.

This article describes several hospital-based medication reconciliation efforts.

Standardizing safety.

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Meyers S. Trustee. 2006;59:12-4, 21, 1.

The author describes how several hospitals implemented crew resource management programs to improve communication.

Practitioners agree on medication reconciliation value, but frustration and difficulties abound.

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ISMP Medication Safety Alert! Acute care edition. July 13, 2006.

This article summarizes the results of Institute for Safe Medication Practices' (ISMP's) national survey on medication reconciliation.

Improving the safety of telephone or verbal orders.

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PA PSRS Patient Saf Advis 2006 Jun;3(2):1,3-7.

This article shares several examples of errors made while verbally communicating medication orders and includes recommendations for safe practices.

Scathing report on Kaiser kidney program. Transplant delays assailed -- Medicare threatens to end coverage.

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Russell S.

This article reports on a Centers for Medicare & Medicaid Services report that details deficiencies in Kaiser's kidney transplant program.

Inquiry into reporter's death finds multiple failures in care.

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This article reports on the investigation following the death of New York Times reporter David E. Rosenbaum. The investigation uncovered a range of failures in emergency care and is described in a report available via the link below.

JCAHO tightens leash on medication reconciliation.

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Perry LE. Drug Topics. March 20, 2006.

This article reports on the Joint Commission's focus on medication reconciliation and illustrates how health care organizations are applying the process to prevent medication errors.

Accuracy at every step: the challenge of medication reconciliation.

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Institute for Healthcare Improvement; IHI

This article reviews the importance of medication reconciliation, discusses the difficulties of building the process into patient care, and shares stories from hospitals that have successfully implemented programs.

Non-English speakers find ERs hard to reach.

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This article reports on a study conducted by the Discrimination Research Center that found non-English speakers were not connected to a staff member who spoke the language in about half of calls to the emergency department.

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