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1 - 11 of 11

Oglethorpe A. Women's Health. November 4, 2020.

Skin condition diagnosis is a visual activity that is vulnerable to error. This article highlights how conditions such as psoriasis and skin cancer can be misdiagnosed. The piece shares recommendations for patients to obtain an accurate diagnosis such as seeking a second opinion and preparing for appointments with notes and questions.

Dembosky A. All Things Considered. National Public Radio. October 15, 2020.

Physician implicit bias is gaining attention as a patient safety concern. This piece shares a story of ineffective care delivery to a patient with COVID-19 as context for the discussion. Hospital tactics to address the problem such as training and use of patient survey data to motivate individual action are reviewed.   

Mann B. All Things Considered. National Public Radio. October 5, 2020.

Clinicians are susceptible for medication misuse due to stress, fatigue, or arrogance. This news article discusses how drug diversion should signal behaviors that can harm patients, the clinicians themselves, and the organizations they work for. Reporting gaps contribute to the perpetuation of the problem. 

ISMP Medication Safety Alert! Acute care edition. August 27, 2020;25(17).

The culture of blame is exacerbated by stress, production pressure, and a negative work environment. This article discusses how medication errors that take place during the care of patients with COVID-19 are not being reported by nurses due to lack of time and psychological safety. Recommendations to avoid this situation include heightening prevention efforts by employing tactics such as deployment of huddles and use of pre-mixed medication solutions.  

Cheney C. HealthLeaders. September 4, 2020.

A blameless approach to error and near miss reporting is foundational to the success of the effort. This article discusses one organization’s persistent challenge with shifting reporting to align with a safety culture. The author describes the importance of staff education and leadership to support the focus of reporting initiatives on the system rather than individuals when failures occur.   
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.

O'Donnell J. USA Today. September 8, 2020

Management and clinical functions to ensure patient safety have been disrupted during the COVID-19 pandemic. This article discusses how tracking and submitting of reports of questionable medical care have been reduced due to redirection of efforts of all to managing pandemic related activities.   
Brody JE. New York Times. 2020.
Inappropriate care activities can cascade to significantly impact patient safety. This article shares how medication side effects can be misdiagnosed to perpetuate harm in older patients rather than getting to the root of the care concerns. 
Klenklen J. Patient Saf Qual HCare. December 19, 2019.
High reliability organizations consistently examine what goes wrong and remain aware that failure can happen at any time. This article discusses a learning model built upon event definition, rapid contributing factor identification, system-focused communication, and standardized learning to facilitate organizational learning from sentinel events.