The risks to patient safety from health system expansions. | PSNet

Provide Feedback |

Submit a Case

Register

Commentary

Emerging Classic

The risks to patient safety from health system expansions.

April 18, 2018

Haas S, Gawande AA, Reynolds ME. JAMA. 2018;319(17):1765-1766.

View more articles from the same authors.

Changes in organizational process and governance can create downstream conditions that result in failures. This commentary explored how system expansion affects safety. The authors highlight the need for leadership to use system data to plan for and manage the impact of the resultant infrastructure and patient population changes on care delivery.

PubMed citation

Related news article

Related news article

Related Resources From the Same Author(s)

Safely practicing in a new environment: a qualitative study to inform physician onboarding practices.

May 13, 2020

Improving safety with information technology.

March 6, 2005

The frequency and significance of discrepancies in the surgical count.

August 27, 2008

Accidental deaths, saved lives, and improved quality.

October 5, 2005

National costs of the medical liability system.

September 15, 2010

Patterns of technical error among surgical malpractice claims: an analysis of strategies to prevent injury to surgical patients.

November 14, 2007

Is WHO's surgical safety checklist being hyped?

August 21, 2019

Incidence, patterns, and prevention of wrong-site surgery.

April 19, 2006

Risk factors for retained instruments and sponges after surgery.

March 6, 2005

Disclosure of medical injury to patients: an improbable risk management strategy.

January 24, 2007

Relationship between occurrence of surgical complications and hospital finances.

April 24, 2013

What I wish I’d known: how experienced physician managers diagnose, treat and prevent disruptive behaviour.

September 21, 2022

Effective surgical safety checklist implementation.

January 30, 2005

Prevention of retained surgical sponges: a decision-analytic model predicting relative cost-effectiveness.

May 27, 2009

Patterns of communication breakdowns resulting in injury to surgical patients.

April 11, 2007

Inadvertent administration of magnesium sulfate through the epidural catheter: report and analysis of a drug error.

January 18, 2006

Bar-coding surgical sponges to improve safety: a randomized controlled trial.

April 23, 2008

Effect of a 19-item surgical safety checklist during urgent operations in a global patient population.

June 2, 2010

Hospital board and management practices are strongly related to hospital performance on clinical quality metrics.

August 19, 2015

Analysis of surgical errors in closed malpractice claims at 4 liability insurers.

August 16, 2006

Perspectives in quality: designing the WHO Surgical Safety Checklist.

September 1, 2010

Communication practices on 4 Harvard surgical services: a surgical safety collaborative.

November 11, 2009

Claims, errors, and compensation payments in medical malpractice litigation.

May 17, 2006

Surgical team member assessment of the safety of surgery practice in 38 South Carolina hospitals.

April 15, 2015

Sentinel events. In memory of Ben—a case study.

March 27, 2005

Scaling safety: the South Carolina Surgical Safety Checklist experience.

January 9, 2019

A policy-based intervention for the reduction of communication breakdowns in inpatient surgical care: results from a Harvard surgical safety collaborative.

July 13, 2011

Simulation-based trial of surgical-crisis checklists.

January 30, 2013

Perception of safety of surgical practice among operating room personnel from survey data is associated with all-cause 30-day postoperative death rate in South Carolina.

August 16, 2017

Implementation of the surgical safety checklist in South Carolina hospitals is associated with improvement in perceived perioperative safety.

May 11, 2016

A cross-sectional analysis investigating organizational factors that influence near-miss error reporting among hospital pharmacists.

August 27, 2014

Associations between communication climate and the frequency of medical error reporting among pharmacists within an inpatient setting.

September 25, 2013

A comparative analysis of incident reporting lag times in academic medical centres in Japan and the USA.

April 28, 2010

Sustainability and long-term effectiveness of the WHO surgical safety checklist combined with pulse oximetry in a resource-limited setting: two-year update from Moldova.

April 8, 2015

Mortality trends after a voluntary checklist-based surgical safety collaborative.

May 3, 2017

Crisis checklists for the operating room: development and pilot testing.

January 30, 2005

Multisource evaluation of surgeon behavior is associated with malpractice claims.

April 11, 2018

The potential of Twitter as a data source for patient safety.

January 27, 2016

Shifting the learning curve.

January 19, 2011

Is there a relationship between high-quality performance in major teaching hospitals and residents' knowledge of quality and patient safety?

November 18, 2009

The effect of collaboration on obstetric patient safety in three academic facilities.

December 4, 2013

Gender biases in estimation of others' pain.

April 28, 2021

The COVID trap: pediatric diagnostic errors in a pandemic world.

August 25, 2021

The growth of rapid response systems.

August 13, 2008

Implementing an MET-based RRS at Toronto General Hospital.

January 16, 2008

On the prospects for a blame-free medical culture.

November 4, 2009

Parent willingness to remind health care workers to perform hand hygiene.

August 14, 2013

Computerized provider order entry implementation: no association with increased mortality rates in an intensive care unit.

July 19, 2006

Hospital nurses' perceptions of human factors contributing to nursing errors.

June 10, 2015

Rapid response teams seen through the eyes of the nurse.

August 4, 2010

Medication safety in acute care in Australia: where are we now? Part 2: a review of strategies and activities for improving medication safety 2002-2008.

October 14, 2009

Medication safety in acute care in Australia: where are we now? Part 1: a review of the extent and causes of medication problems 2002-2008.

September 16, 2009

Expert consensus on currently accepted measures of harm.

September 9, 2020

Challenges and potential solutions for patient safety in an infectious-agent-isolation environment: a study of 484 COVID-19-related event reports across 94 hospitals

September 1, 2021

Reducing surgical mortality in Scotland by use of the WHO Surgical Safety Checklist.

May 8, 2019

Impact of a hospital-wide hand hygiene initiative on healthcare-associated infections: results of an interrupted time series.

September 5, 2012

Changes in safety attitude and relationship to decreased postoperative morbidity and mortality following implementation of a checklist-based surgical safety intervention.

February 9, 2011

Pilot testing of a model for insurer-driven, large-scale multicenter simulation training for operating room teams.

December 11, 2013

Medication safety alert fatigue may be reduced via interaction design and clinical role tailoring: a systematic review.

July 31, 2019

The evidence base for US Joint Commission hospital accreditation standards: cross sectional study.

July 13, 2022

Perianesthesia nursing advocacy: an influential voice for patient safety.

June 11, 2008

Outreach and Early Warning Systems (EWS) for the prevention of Intensive Care admission and death of critically ill adult patients on general hospital wards.

August 8, 2007

Infusional chemotherapy and medication errors in a tertiary care pediatric cancer unit in a resource-limited setting.

November 13, 2013

Do no harm: reaffirming the value of evidence and equipoise while minimizing cognitive bias in the COVID-19 era.

August 12, 2020

Resident supervision and patient safety: do different levels of resident supervision affect the rate of morbidity and mortality cases?

August 26, 2015

A novel tool for organisational learning and its impact on safety culture in a hospital dispensary.

June 20, 2012

Are quality improvement collaboratives effective? A systematic review.

January 10, 2018

Allocation of physician time in ambulatory practice: a time and motion study in four specialties.

September 7, 2016

Communication factors in the follow-up of abnormal mammograms.

March 6, 2005

Residency Training—A Decade of Duty-Hour Regulations.

December 18, 2013

How is medication prescribing ceased? A systematic review.

November 24, 2010

Using failure mode and effects analysis to plan implementation of smart i.v. pump technology.

August 23, 2006

An investigation of the relationship between safety climate and medication errors as well as other nurse and patient outcomes.

December 13, 2006

Situation, background, assessment, and recommendation–guided huddles improve communication and teamwork in the emergency department.

December 16, 2015

An assessment of basic patient safety skills in residents entering the first year of clinical training.

June 6, 2018

A surgical safety checklist to reduce morbidity and mortality in a global population.

January 21, 2009

Parent-reported errors and adverse events in hospitalized children.

March 16, 2016

Parent–provider miscommunications in hospitalized children.

August 23, 2017

Assessing and monitoring override medications in automated dispensing devices.

May 31, 2006

Designing for distractions: a human factors approach to decreasing interruptions at a centralised medication station.

November 14, 2012

Another surgeon's error: must you tell the patient?

October 15, 2014

Complication rates, hospital size, and bias in the CMS Hospital-Acquired Condition Reduction Program.

January 25, 2017

Reasons why physicians and advanced practice clinicians work while sick: a mixed-methods analysis.

July 15, 2015

Effects of learning climate and registered nurse staffing on medication errors.

January 5, 2011

Nurse staffing and medication errors: cross-sectional or longitudinal relationships?

October 29, 2008

Safety measurement and monitoring in healthcare: a framework to guide clinical teams and healthcare organisations in maintaining safety.

May 21, 2014

A human factors curriculum for surgical clerkship students.

January 5, 2011

Communication and shared understanding between parents and resident-physicians at night.

July 13, 2016

A relational leadership perspective on unit-level safety climate.

November 9, 2011

Medication errors with pediatric liquid acetaminophen after standardization of concentration and packaging improvements.

October 17, 2018

State medical board regulation of compounding in physician offices.

June 9, 2021

The safety of inpatient health care.

January 25, 2023

When diagnostic testing leads to harm: a new outcomes-based approach for laboratory medicine.

September 11, 2013

Preventing mistransfusions: an evaluation of institutional knowledge and a response.

February 21, 2018

Associations between perceived crisis mode work climate and poor information exchange within hospitals.

February 4, 2015

The road to zero preventable birth injuries.

April 9, 2008

Impact of computerized prescriber order entry on the incidence of adverse drug events in pediatric inpatients.

November 21, 2007

How event reporting by US hospitals has changed from 2005 to 2009.

October 12, 2011

Checklists to prevent diagnostic errors: a pilot randomized controlled trial.

July 8, 2015

Antecedents of severe and nonsevere medication errors.

April 22, 2009

View More

Related Resources

To do no harm - and the most good - with AI in health care.

March 13, 2024

Towards a common framework to support decision-making in high-risk, low-time environments.

March 6, 2024

Community Health Systems’ ongoing journey to zero preventable harm.

December 6, 2023

Five strategies for a safer EHR modernization journey.

December 6, 2023

On Patient Safety.

November 7, 2023

Bringing the equity lens to patient safety event reporting.

October 25, 2023

Abbreviation use decreases effective clinical communication and can compromise patient safety.

October 4, 2023

Compendium of Strategies to Prevent HAIs in Acute Care Hospitals 2022.

September 11, 2023

Mind the power gap: how hierarchical leadership in healthcare is a risk to patient safety.

August 30, 2023

Sociotechnical work system approach to occupational fatigue.

July 26, 2023

Patient safety 2.0: slaying dragons, not just investigating them.

July 19, 2023

Roadmap to Health Care Safety for Massachusetts.

May 3, 2023

The effect of documenting patient weight in kilograms on pediatric medication dosing errors in emergency medical services.

May 3, 2023

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

CHaMP: A model for building a center to support health care worker well-being after experiencing an adverse event.

April 5, 2023

Improving safety by evaluating the impact of the supply chain and drug shortages on health-systems.

March 29, 2023

Addressing Medical Gaslighting to Improve Maternal Health—Together.

March 29, 2023

Patient Safety Innovations

The I-READI Quality and Safety Framework: Strong Communications Channels and Effective Practices to Rapidly Update and Implement Clinical Protocols During a Time of Crisis

March 15, 2023

An infrastructure to provide safer, higher quality, and more equitable telehealth.

March 1, 2023

Impact of the COVID-19 pandemic on the experiences of hospitalized patients: a scoping review.

February 22, 2023

An evidence and consensus-based definition of second victim: a strategic topic in healthcare quality, patient safety, person-centeredness and human resource management.

February 15, 2023

National patient safety goal to improve health care equity.

February 8, 2023

Contributors to diagnostic error or delay in the acute care setting: a survey of clinical stakeholders.

October 12, 2022

Pharmacy leadership amid the pandemic: maintaining patient safety during uncertain times.

September 14, 2022

Improving diagnosis: adding context to cognition.

September 7, 2022

Advancing Anticoagulation Stewardship: A Playbook.

September 7, 2022

Reducing administrative harm in medicine - clinicians and administrators together.

July 6, 2022

Differences in medication reconciliation interventions between six hospitals: a mixed method study.

June 29, 2022

A learning health system agenda for organizational approaches to enhancing occupational well-being among clinicians.

May 25, 2022

Intrapersonal and institutional influences on overall perception of radiation safety among radiologic technologists.

April 6, 2022

View More

See More About The Topic

Facility and Group Administrators

Epidemiology of Errors and Adverse Events

Policies and Operations

To sign up for updates or to access your subscriber preferences, please enter your email address below.

5600 Fishers Lane
Rockville, MD 20857
Telephone: (301) 427-1364