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
Additional Filters
1 - 20 of 377

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.

Rau J. Kaiser Health News. February 8, 2022. 

Rating systems face challenges to accurately represent the safety and quality of patient care. This article discusses inconsistent results between national rating systems and those organizations penalized by the Hospital-Acquired Condition Reduction Program though reduction of Medicare payments for hospitals recording certain adverse events.

Ackerman RS, Patel SY, Costache M, et al. Anesthesiology News. November 21, 2021.

Blame is known to limit discussions of near-misses and failures, which negatively impacts learning and incident reduction. This article describes work to examine blameful context present in anesthesiology incident documentation, reducing its viability as a successful investigation record. Length of text was identified as an enabler of blameful orientation, and limitations as to word count were one strategy to minimize the use of punitive language.

Pasztor A. Wall Street Journal. September 2, 2021.

Aviation continues to serve as an exemplar for healthcare safety efforts. This story highlights work toward the development of a National Patient Safety Board for medicine to establish a neutral centralized body to examine errors and share improvements driven by a robust self-reporting culture similar to that in commercial aviation.

ISMP Medication Safety Alert! Acute care edition. August 26, 2021;26(17);1-5. 

Error reporting is an essential contributor to system safety improvement. This article examines weaknesses in error reporting behaviors, characteristics of organizations and technologies that facilitate underreporting and ineffective report analysis. The piece shares recommendations to enhance adverse event reporting to support learning.

Carr S. ImproveDx. July 2021;8(4).

Adverse event reporting can clarify when mistakes happen and what reduction strategies to apply. This article describes existing efforts to examine diagnostic error through reporting and highlights tactics being employed.

Silver-Greenberg J, Gebeloff R. New York Times. March 13, 2021.

The value of rating systems can be challenged by bias and misinterpretation due to a variety of factors. This article outlines how nursing home patients fell victim to both systemic and care failings in the US nursing homes, yet their facilities still ranked high in a national rating system. The authors discuss failures including the lack of data auditing and a focus on ratings rather than quality.

ISMP Medication Safety Alert! Acute Care. March 11, 2021;26(5):1-6.

Skin patches are a convenient medication delivery method but may harbor unique threats to safety. This article examines transdermal patch errors submitted to a national reporting program to provide safety improvement insights. Recommendations suggested for improvement focus on topics such as prescribing, patch management upon hospital admission, and labeling issues.

Cornelissen C, Call RC, Harbell MW, et al. APSF Newsletter. February 202136(1);25-27

Error disclosure is supported by a robust safety culture and a defined communication and management approach. This article discusses the engagement of anesthesiologists in the disclosure processes to ensure learning, patient centeredness, and care improvement.

Boodman SG. Washington Post. February 20, 2021.

Difficult diagnostic journeys are compounded by lack of clinician empathy, bias awareness, and critical thinking. This piece shares the story of a patient whose efforts to identify the cause of her pain were hampered by heuristics, premature closure, and poor patient relationship building.

Rau J. Kaiser Health News. February 19, 2021.

Financial incentives have shown both benefits and limitations in addressing hospital-acquired harm. This news article summarizes an annual tally of hospitals facing Medicare payment reductions for high rates of infections and other preventable hospital-acquired conditions.

ISMP Medication Safety Alert! Acute care edition. January 27, 2021;26(2).

Medication safety is challenged by both persistent problems and emerging situations. This article summarizes reports of errors submitted voluntarily to the Institute for Safe Medication Practices (ISMP) in 2020. The set list includes both pandemic-related hazards and common problems such as use of abbreviations and opioid-naïve patient prescribing. 

Phipps D, Ashour A, Riste L, et al. The Pharmaceutical Journal. 2020;305(7943, 7944). November 10, December 1, 2020.

Dispensing mistakes are a common contributor to preventable adverse events in community pharmacies. Part 1 of this two-part series discusses factors that contribute to dispensing errors and summarizes methods for managing risks stemming from missteps. Part 2 focuses on preventing situations that enable errors and the role pharmacists have in minimizing dispensing errors in daily practice.

ISMP Medication Safety Alert! Acute care edition. December 3, 2020;25(24).

Infusion misadministration is not always immediately evident. This story illustrates the problem of underdosing during infusions and suggests that unclear policies and lack of problem awareness contribute to the persistence of the mistake. The piece recommends education, use of data, and storytelling as tactics to reduce underdosing.

Heath S. Patient Engagement HIT. October 29, 2020.

Twitter is evolving as a useful data source for patient safety. This news story discusses an examination of public use of a patient-complaint hashtag that recorded patient experiences of misdiagnosis, disrespect and miscommunication that contributed to poor relations with physicians, medical errors, and harm.

ISMP Medication Safety Alert! Acute Care Edition. October 8, 2020;25(20):1-4

In-depth investigations provide multidisciplinary insights that inform sustainable improvement opportunities. This newsletter story highlights a drug administration error examination by a dedicated office in the United Kingdom highlight the value of a commitment to deep, non-punitive analysis of patient safety incidents to enable transparency and learning.

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.