Busch IM, Saxena A, Wu AW. J Patient Saf. 2021;17:358-362.
In this literature review, the authors identified patient-, clinician-, and institutional-level barriers to patient involvement in patient safety investigations. Potential strategies for overcoming barriers are also discussed, such as adopting a blame-free climate and enhancing clinician training in error disclosure and communication.
This organization shares best practices to align and optimize efforts toward eliminating patient harm by the year 2030. The Foundation supports several awareness initiatives to drive improvements associated with its strategic aims that include promoting transparency, realigning safer care incentives, and informing patients and families about patient safety.
Clinicians are often reluctant to report impaired or incompetent colleagues. This newspaper article discusses how a Veterans Affairs system pathologist with substance addiction continued to misdiagnose patients despite performance concerns raised by colleagues.
This website tracks the progress of a project focused on the development and review of measures to enhance viability, reporting, accountability, and impact of health care organization efforts to reduce diagnostic error. The committee's final report is now available.
Palmer J. Patient Saf Qual Healthc. May/June 2019.
Organizations must learn from adverse events to prevent similar incidents. Reporting on lessons to be learned from the cascade of failures connected with the preventable death of a patient during an acute asthma attack at the door of a hospital emergency department, this magazine article outlines the importance of effective signage, appropriate security staff placement, and acceptance of the responsibility for failure.
Transparency has been heralded as a cornerstone to improvement in health care. This news article reports on a government alternative summary reporting program that allowed medical device makers to conceal safety events and malfunction reports associated with medical devices. A new program that expands access to information about device-related failures will be put in place.
Pettersen B, Tate J, Tipper K, McKean H. Colorado Senate Bill 19-201.
Communication-and-resolution mechanisms are seen as important approaches to improving transparency and healing after an adverse event. This state bill, referred to as the "Colorado Candor Act," protects conversations between organizations, clinicians, patient, and families from legal discoverability and outlines criteria to guarantee that protection.
Cullen A. Uitgeverij van Brug: The Hague, The Netherlands; 2019. ISBN: 9789065232236.
Patient stories offer important insights regarding the impact medical errors have on patients and their families. This book shares the author's experience with medical error and spotlights how lack of transparency in European health care can contribute to avoidable process failures that result in patient harm.
This news article reports on the documentary To Err Is Human, which was produced and directed by the son of patient safety leader Dr. John M. Eisenberg. The film is structured around patient safety advocate Sue Sheridan's experience with diagnostic errors that resulted in harm for both her son and husband. It features a wide range of experts who discuss the impact of error on all involved, the role of culture in facilitating both mistakes and progress, and why continued work in health care safety is needed.
Hixenbaugh M, Ornstein C. Houston Chronicle and Propublica. May 2018-May 2019.
This news investigation chronicles a series of incidents in a transplant program that resulted in patient harm. The systemic nature of the problems such as insufficient whistleblower protection, accountability, and follow-up on patient concerns culminated in a change of hospital leadership. A previous PSNet interview with Charles Ornstein discussed the role of media in raising awareness of patient safety issues.
Bell SK, Folcarelli P, Fossa A, et al. J Patient Saf. 2018;17:e791-e799.
Safety issues are common in the ambulatory care setting, but they can be difficult to detect because patients may spend months between contacts with the health care system. Engaging patients in their care is a recommended strategy to improve ambulatory safety and is the focus of a recent AHRQ toolkit. The OpenNotes initiative—in which patients have the opportunity to review and edit their medical records contemporaneously—aims to improve patient engagement and patient safety through promoting transparency. In this study, patients and caregivers with OpenNotes access were surveyed regarding the perceived effect of accessing notes on their understanding of their medical conditions and the patient–clinician relationship. Overall, most participants felt that accessing OpenNotes facilitated their understanding of the rationale for tests and referrals and improved their relationship with primary care providers. Although hindered by a low response rate, this study provides some support for the proposition that increased transparency can enhance patient engagement.
Although providing patients with access to physician notes and test results supports transparency and patient engagement, it can also introduce certain challenges. This newspaper article reports on unintended psychological stresses associated with direct patient access to test results without appropriate contextual information. Improvement strategies include use of graphics, timely patient-centered communication, and scheduling appointments to discuss results. A PSNet perspective explored how patient-facing technologies can empower patients and improve safety.
Makary M. New York, NY: Bloomsbury Press; 2012. ISBN: 9781608198368.
This book, written by a Johns Hopkins University surgeon and patient safety researcher, highlights the problems of medical errors and poor quality care, and argues that meaningful solutions must include new levels of transparency and patient engagement.
This video series uses two real cases of patients who died due to preventable errors after elective surgery to illustrate fundamental concepts in patient safety and provide lessons for patients and families in engaging in their own care. The circumstances leading to the death of Lewis Blackman, one of the patients discussed in this video series, are discussed in more detail in a separate article that analyzes his death as an example of failure to rescue.
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