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1 - 14 of 14

DePeau-Wilson M. MedPage Today. May 13, 2022. 

Disciplinary actions against clinicians who err continue despite awareness efforts to inhibit them. This article summarizes reaction to the sentencing of a nurse in a high-profile medication error case. It discusses reverberations throughout healthcare that will affect patient safety efforts.

Loller T. Associated PressMarch 30, 2022.

Reporting medical errors, learning from them, and improving systems is a cornerstone of improving patient safety. A just culture centers on moving from blaming individuals for medical errors towards a systems-based approach to learning what went on, in order to prevent similar errors in the future. The recent conviction of a nurse involved in the death of a patient has raised concerns that clinicians may not disclose medical errors out of fear of criminal prosecution and conviction.

Fiore K. MedPage Today. March 28, 2022.

Experts are concerned that convictions for medical error have the potential to limit dialogue on the front line about medical mistakes. This article summarizes discussions regarding the verdict to convict a nurse due to a workaround that resulted in a medication error and patient death.

US House of Representatives Committee on Veterans' Affairs Subcommittee on Health.  117th Cong. 1st Sess (2021).

The Veterans Health Administration is a large complex system that faces various challenges to safe care provision. At this hearing, government administrators testified on current gaps that detract from safe care in the Veteran’s health system. The experts discussed several high-profile misconduct and systemic failure incidents, suggested that the culture and leadership within the system overall enables latency of issues, and outlined actions being taken to address weaknesses.

Agency for Healthcare Quality and Research. Fed Register. August 31, 2021;86:48703-48705.

This announcement calls for public comment on the intention of the Agency for Healthcare Research and Quality to launch the Ambulatory Surgery Center Survey on Patient Safety Culture Database data collection process. The comment period is closed.
O'Neill N. Nursing (Brux). 2021;51:54-56.
Individuals who express concerns can identify latent conditions that degrade safety in health care. This article examines this behavior in the context of the COVID pandemic and staff safety. The author highlights instances of peer and organizational retaliation against whistleblowers.

Horowitz SH. Washington Post. October 4, 2020.

The harm of misdiagnosis can be extended by lack of clinician recognition and acceptance of the error when a patient raises concerns. This news story shares the experience of a physician-patient whose recognition of a diagnostic mistake was initially dismissed. The author defines the repeated lack of organizational willingness to resolve the situation as a normalized deviance in health care.

London, UK: The Parliamentary and Health Service Ombudsman; July 15, 2020. ISBN 9781528620666.

Patient and family complaints can provide insights into system weaknesses if managed effectively. This report examined complaint handling at the United Kingdom National Health Service. The analysis found that lack of training, consistency and learning orientation reduced the effectiveness of the effort.

Organisation for Economic Co-operation and Development.

Organizations worldwide are focusing efforts on reducing the conditions that contribute to medical error. This website provides a collection of reports and other resources that cover activities and concerns of the 37 member countries active in the organization to address universal challenges to patient safety.
Yong E. The Atlantic. 2020;September.
This article takes a holistic view of the multiple preventable failures of the U.S. in managing the COVID-19 pandemic, raising several patient safety issues from the metasystems perspective. The piece highlights systemic problems such as lack of transparency, investment in public health and learning from experience.

People’s Pharmacy.  Show 1209. April 28, 2020.

Accidental harm to patients is a persistent challenge in health care. This interview features Dr. Danielle Ofri who provides an overview of error in medicine. She draws from both general and COVID-19 pandemic care experiences to illustrate the difficulties involved in measuring, understanding and improving patient safety.
Human factors expertise in targeted personnel is a noted health care system improvement strategy. This news piece highlights the National Health Service (NHS) effort to require organizations to develop and employ patient safety specialists with distinct human factors and safety science skill sets to embed system improvements in their organizations and throughout the NHS.