Skip to main content

All Content

Search Tips
Save
Selection
Format
Download
Published Date
Original Publication Date
Original Publication Date
PSNet Publication Date
Narrow Results By
PSNet Original Content
1 - 20 of 46
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.
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.
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.

Gabler E. Milwaukee Journal Sentinel. May 15, 2015.

Reporting on weaknesses in laboratory testing methods, this news article discusses patients' experiences with testing errors to illustrate how such failures can contribute to patient harm—such as missed or delayed diagnosis—and raises concerns about insufficient transparency, investigations, and regulations around laboratory facilities with poor processes.
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.
Gubar S.
This newspaper article describes how surgical complications, health care–associated infections, and ineffective patient–provider communication contributed to a patient's experience with harm and suggests that transparency around the incident and preoperative patient briefings could have improved the situation.
Flatten M. Washington Examiner. August 18–22, 2014.
This series offers five magazine articles exploring how diagnostic error, delayed treatment, and insufficient attention to patient concerns and medical history within the Veterans Affairs health system contributed to preventable harm and death.

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.

Landro L. Wall Street Journal. June 9, 2014.

As they become more prevalent, electronic medical records (EMRs) are being used to improve safety in increasingly creative ways. This newspaper article reports on efforts to engage patients in reviewing their medication lists by providing them with access to EMR systems in order to detect and correct discrepancies in data.
Lord T. Patient Saf Qual Healthc. March/April 2012;9:38-41,44.
This article details how miscommunication and lack of patient-centered care contributed to errors that led to the death of a child.