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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.
Lagisetty P, Macleod C, Thomas J, et al. Pain. 2021;162:1379-1386.
Inappropriate prescribing of opioids is a major contributor to the ongoing opioid epidemic. This study involved simulated patients with chronic opioid use who called primary care clinics in need of a new provider because their previous physician had retired or stopped prescribing opioids. Findings indicate that primary care providers were generally unwilling to prescribe opioids to patients whose histories are suggestive of misuse, which may raise access to care concerns and cause potential unintended harm for some patients.  

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.   
A 52-year old women presented to the emergency department with a necrotizing soft tissue infection (necrotizing fasciitis) after undergoing cosmetic abdominoplasty (‘tummy tuck’) elsewhere. A lack of communication and disputes between the Emergency Medicine, Emergency General Surgery and Plastic Surgery teams about what service was responsible for the patient’s care led to delays in treatment. These delays allowed the infection to progress, ultimately requiring excision of a large area of skin and soft tissue.
To transfer a man with possible sepsis to a hospital with subspecialty and critical care, a physician was unaware of a formal protocol and called a colleague at the academic medical center. The colleague secured a bed, and the patient was sent over. However, neither clinical data nor the details of the patient's current condition were transmitted to the hospital's transfer center, and the receiving physician booked a general ward bed rather than an ICU bed. When the patient arrived, his mentation was altered and breathing was rapid.
DeMarco P. Globe Magazine. November 3, 2018.
This magazine article reports on the preventable death of a patient during an acute asthma attack. Written by the patient's husband, the article outlines the failures that led to her death despite the fact that she was at the door of a hospital emergency department and on the phone with an emergency dispatcher. Factors discussed include overreliance on poorly functioning technology, communication failures, and lack of fail-safes.
Triller D, Myrka A, Gassler J, et al. Jt Comm J Qual Patient Saf. 2018;44:630-640.
Patients prescribed high-risk medications, including anticoagulants, are at increased risk for adverse drug events and may be particularly vulnerable during care transitions. This study describes how a multidisciplinary panel of anticoagulation experts used an iterative consensus-building process to determine what information should be communicated to relevant providers for all patients on anticoagulation undergoing a transition in care.
Richter JP, McAlearney AS, Pennell ML. Health Care Manage Rev. 2016;41:32-41.
Incomplete handoffs and insufficient communication regarding key clinical information may lead to adverse events or missed or delayed diagnoses. This analysis of data from the AHRQ Hospital Survey of Patient Safety Culture sought to determine how perceptions of organizational factors that affect safety can contribute to optimal handoffs. Perceived teamwork across units was a significant predictor for successful handoffs. Perceptions of staffing adequacy and management support for patient safety efforts were also related to good handoffs. Among frontline staff, open communication was associated with optimal handoffs, while among management safe handoffs were linked to a continuous learning culture. These findings add to existing studies which underscore the need for high-reliability organizations to promote safety efforts. The authors advocate for hospital leadership to promote teamwork and open communication to augment handoffs in their facilities. Dr. Vineet Arora discussed the challenges of handoffs in a prior AHRQ WebM&M interview.
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.
Cohen MR, Smetzer JL. Hosp Pharm. 2010;45.
This monthly column highlights an initiative to introduce safer device connectors to prevent spinal and epidural medications from being delivered intravenously, discusses the value of independent double-checks, and shares thoughts on the 35th anniversary of this column.
Kaplan LJ, Maerz LL, Schuster KM, et al. The Journal of Trauma: Injury, Infection, and Critical Care. 2009;67.
Since adoption of the 2003 ACGME duty hour restrictions, targeted curricular and information technology initiatives have emerged to address safe handoffs in care. This study analyzed surgical rapid response team (RRT) calls to determine if greater discontinuity in care was a potentially contributing factor. Investigators found that impending respiratory failure and acute volume overload were the most common conditions prompting RRT activation. However, the more noteworthy findings were that RRT activations most frequently occurred during times of cross-coverage, resulted from team-based errors of omission, and were frequently preventable or potentially preventable events. A past AHRQ WebM&M commentary discussed a case of a failed signout process that contributed to a delay in treatment and diagnosis.