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Bendix J. Med Econ. November 25, 2019;96(23);10-14.
Implicit biases can compromise decision making due to the effect they can have on heuristics, communication and patient/physician communication. This article shares reasons for these biases and shares tactics to minimize their impacts which include being mindful of biases and a personalized approach to patients.
Butcher L.
Inconsistent patient name entry practices in electronic health records can contribute to wrong-patient errors. This magazine article reports on the complex nature of addressing patient-matching discrepancies as an economic, privacy, and technical problem. Improvement strategies include the development and adoption of a national identification program and biometric technology. A WebM&M commentary discussed problems associated with name similarities in the electronic patient record.
Peeples L.
Structured handoffs can reduce communication problems that contribute to medical error. This magazine article reports on how I-PASS implementation can help enhance the quality and completeness of handoffs, highlights the need for pharmacists to be more engaged in handoff improvement, and offers insights for enhancing their role in the process. In a past PSNet interview, Dr. Amy Starmer discussed the implementation and findings of the landmark I-PASS study.
Sederstrom J.
Medication errors continue to be a worldwide patient safety challenge that requires both systems and individual practice strategies for improvement. This magazine article describes how pharmacists can address failures associated with processing, dosing, care transitions, and information sharing to prevent medication errors.
Ready T.
Transitions are an error-prone process. This news article reports that organizational leadership should be engaged in enhancing safety of transitions and facilitating design of sustainable improvements. The article also highlights successful interventions that have benefited from leadership engagement, such as the I-PASS program.
Clements K. Nursing Management (Springhouse). 2017;48.
High reliability has yet to be achieved in health care organizations. This magazine article described how a 13-hospital health system used handoff standardization tools such as I-PASS to enhance the reliability of patient transitions.
Gardner LA. PA-PSRS Patient Saf Advis. 2016;13:58-65.
Insufficient health literacy is a known patient safety hazard. This article reviews incidents submitted to a state reporting initiative where insufficient patient understanding may have played a role in delayed or missed care and describes a program to encourage adoption of teach-back and other strategies to help patients better comprehend their health care instructions. A past PSNet perspective discussed the role of health literacy in patient safety.
Rau J.
Transitions in care between inpatient and outpatient settings are an increasing concern for patient safety. Reporting on a fatal medication error that was missed by a patient's pharmacist and home health nurses, this newspaper article discusses various risks associated with hospital-to-home transitions such as insufficient case management and communication.
Quick Safety. November 30, 2015;(18):1-3.
Patient engagement is increasingly recognized as a key strategy to enhance safety in health care. This article describes how failure to communicate effectively with patients can reduce safety and outlines tactics to involve patients and families in care transitions.
Bond A.
Clinician communication with patients and families during transitions has been a focus of safety improvement efforts. This newspaper article describes insights from a resident physician regarding how poor communication between teams caring for patients can result in unnecessary care, family discomfort, and confusion for the patient receiving different information among varying teams.
LaFraniere S. New York Times. April 19, 2015.
Reporting on a case involving an overlooked test result that contributed to the death of a patient in the military medical system, this newspaper article highlights how insufficient transparency can prevent patients and their families from learning about what happened during their care and hinder opportunities to recognize processes in need of improvement.
Agency for Healthcare Research and Quality; AHRQ.
This article describes an intervention that trained health coaches to use mobile technology to assess the health status of recently discharged Medicare patients, first during an in-home visit 48 hours after leaving the hospital and then with weekly phone calls over a 3-week period. The program resulted in decreased readmission rates and significant cost savings.

LaFraniere S, Lehren AW. New York Times. June 28, 2014.

Reporting on serious lapses in the care provided by the military health system, this newspaper article highlights how systemic problems, such as inadequate review of incidents, poor communication, and lack of transparency, can contribute to patient harm.