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Gupta K, Szymonifka J, Rivadeneira NA, et al. Jt Comm J Qual Patient Saf. 2022;Epub May 28.
Analysis of closed malpractice claims can be used to identify potential safety hazards in a variety of clinical settings. This analysis of closed emergency department malpractice claims indicates that diagnostic errors dominate, and clinical judgment and documentation categories continue to be associated with a higher likelihood of payout. Subcategories and contributing factors are also discussed.

Farnborough, UK: Healthcare Safety Investigation Branch; June 2022.

Handoffs between prehospital emergency medical services (EMS) providers and hospital emergency departments (EDs) can be suboptimal, which increases patient harm potential. This interim report examines National Health Service discharge delays. It suggests a systemic approach is needed to address flow and capacity factors that contribute to ineffective and unsafe interfacility discharge and transfer.

Cleghorn E. New York, NY: Dutton; 2021. ISBN: 9780593182956.

Women have been affected by implicit bias that undermines the safety of their care and trust in the medical system. This book shares the history anchoring the mindsets driving ineffective care for women and a discussion of the author’s long-term lupus misdiagnosis.

Medscape Medical News. May 12, 2021.

Delays and mistakes in health care for distinct patient populations hold improvement lessons for the broader system. This news story highlights problems in correctional system cancer diagnoses and treatment that may indicate other types of prison care delivery problems.
Waldman A, Kaplan J. ProPublica. 2020.
Hospitals have been deeply challenged to provide effective care during the COVID crisis. This article discusses how rationing and ineffective protection for families and patients may have contributed to preventable death and the spread of the virus in families due to unnecessary referrals of patients to home care and hospice.
Gallagher R, Passmore MJ, Baldwin C. Med Hypotheses. 2020;142:109727.
The authors of this article suggest that offering palliative care services earlier should be considered a patient safety issue. They highlight three cases in which patients in Canada requested medical assistance in dying (MAiD). The patients in two of the cases were never offered palliative care services, and this could be considered a medical error – had they been offered palliative care services, they may have changed their mind about MAiD, as did the patient in the third case study.

Office of the Inspector General. Washington, DC: Department of Veterans Affairs; July 28, 2020. Report Number 19-07507-214.

Patient suicide is a never event. This report analyzes the death of a veteran after presenting at an emergency room with suicidal ideation. The analysis found lack of both suicide prevention policy adherence and appropriate assessment, as well as a lack concern for the patient’s condition contributed to the failure.   

Linnane R, Diedrich J. Milwaukee Journal Sentinel. February 25, 2020.

Delays in emergency room (ER) triage and assessment contribute to wide range of failures that degrade patient safety. This news story highlights the findings of a government report highlighting overcrowding and production pressures as factors resulting in the death of a patient waiting for care who initially presented at the ER with symptoms of heart attack.
Farnborough, UK; Healthcare Safety Investigation Branch; December 18, 2019.
Maternal care during and after childbirth is at risk for never events including retained foreign objects. This analysis of a sentinel event involving a retained surgical tampon after childbirth discusses communication, fatigue, and process factors that contributed to the incident. The report suggests improved handoffs as one improvement strategy.
Amalberti R, Brami J. BMJ Qual Saf. 2012;21:729-36.
The systems approach to analyzing adverse events emphasizes how active errors (those made by individuals) and latent errors (underlying system flaws) contribute to preventable harm. Adverse events in ambulatory care may arise from an especially complex array of latent errors. This paper explores the role of time management problems, which the authors term "tempos," as a contributor to errors in ambulatory care. Through a review of closed malpractice claims, the authors identify 5 tempos that can affect the risk of an adverse event: disease tempo (the expected disease course), patient tempo (timing of complaints and adherence to recommendations), office tempo (including the availability of clinicians and test results), system tempo (such as access to specialists or emergency services), and access to knowledge. The role of these tempos in precipitating diagnostic errors and communication errors is discussed through analysis of the patterns of errors in malpractice claims. A preventable adverse event caused by misunderstanding of disease tempo is discussed in this AHRQ WebM&M commentary.
Interrupted during a telephone handoff, an ED physician, despite limited information, must treat a patient in respiratory arrest. The patient is stabilized and transferred to the ICU with a presumed diagnosis of aspiration pneumonia and septic shock. Later, ICU physicians obtain further history that leads to the correct diagnosis: pulmonary embolism.
A code blue is called on an elderly man with a history of coronary artery disease, hypertension, and schizophrenia hospitalized on the inpatient psychiatry service. Housestaff covering the code team did not know where the service was located, and when the team arrived, they found their equipment to be incompatible with the leads on the patient.
Owing to privacy concerns, a nurse draws the drapes on a 3-year-old child in recovery following surgery, and unfortunately does not realize the child is in distress until loud inspiratory stridor is heard.