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Sun LH. The Washington Post. October 13, 2016.
Medical devices can contribute to the spread of health care–associated infections. This news article discusses a government report that raises concerns that patients may have been exposed to a deadly bacterial infection related to an essential piece of equipment used in cardiac surgery worldwide. The resulting infection can be difficult to diagnosis as symptoms may remain dormant for months after the initial exposure.
Gittlen S. HealthLeaders Media. October 1, 2016.
The recent recognition of diagnostic error as a blind spot in health care has driven the need to enhance diagnosis. This news article reports how health systems, academic medical centers, and ambulatory care facilities are working to address diagnostic error with efforts focused on teamwork, cognitive bias, and improved reporting.
Whitman E. Mod Healthc. September 25, 2016.
Misidentification of patients can result in problems such as medication administration delays, blood transfusion mismatches, and wrong-patient surgery. This magazine article reviews recent research on this issue and suggests several system approaches for improvement, including the use of patient photos in electronic health records and standardizing patient identification processes.
Furfaro H. Wall Street Journal. September 25, 2016.
Medication errors in pediatric care are common in the hospital and at home. This newspaper article reports on problems associated with medication safety among pediatric patients and highlights several tools both clinicians and parents can use to enhance safety when administering medicine to children, including dosage calculators and pictures depicting medication administration processes.
Rider BB, Gaunt MJ, Grissinger M. PA-PSRS Patient Saf Advis. 2016;13:81-91.
Hobson K. US News News and World Report. September 13, 2016.
Diagnostic error has recently gained recognition as an important patient safety concern. This news article relates the experiences of patients who were misdiagnosed and discusses avenues for improvement such as exploring physician problem-solving behaviors and using trigger tools to detect potential lapses in care.
Innes S. Arizona Daily Star. September 12, 2016.
Delayed diagnoses can have serious consequences. This news article reviews several examples of misdiagnosis and insights from the patients and families involved, explores the importance of engaging patients in determining correct diagnoses, and places the discussion in the broader context of efforts to reduce diagnostic error.
ISMP Medication Safety Alert! Acute Care Edition. September 8, 2016;21:1-4.
Over-reliance on technology can contribute to error due to user complacency. Reviewing how the tendency to trust in the correctness of information from technology can diminish human decision-making, this newsletter article offers strategies to address the problem including training clinicians to assess the reliability of the technology with monitoring and verification activities.
McNeill R, Nelson DJ, Abutaleb Y. Reuters Investigation. September 7, 2016.
Antimicrobial resistance is a pervasive threat to patient safety. This news article discusses incidents involving methicillin-resistant Staphylococcus aureus (MRSA) infection to spotlight the need for health care to develop system-level approaches to measuring the problem and enforce regulations designed to prevent health care–associated infections. A PSNet perspective described one nurse's experience with MRSA as a patient.
MacLean L, Coombs C, Breda K. Nurs Manage. 2016;47:30-34.
Gorman A. Kaiser Health News. August 30, 2016.
Older patients are particularly vulnerable to medication errors, as they are often prescribed multiple medications for chronic conditions. This news article reports on complexities associated with managing medications in older patients, including how miscommunication between care team members and patient misunderstanding of postdischarge medication changes can increase risks and contribute to preventable harm. A recent WebM&M commentary discussed strategies to safely manage medications in older patients and highlighted the importance of medication reconciliation.
ISMP Medication Safety Alert! Acute Care Edition. August 25, 2016;21:1-3.
Reporting the results of a survey on "as directed" instructions for medications and summarizing cases of misunderstandings resulting from the practice, this newsletter article recommends that physicians should provide explicit directions regarding medication administration steps to patients to ensure medications are used safely and pharmacists are able to provide appropriate patient counseling if required.
Kowalczyk L. Boston Globe. August 14, 2016.
Certain elements of the ambulatory surgery environment can increase risk of adverse events. Reporting on a series of patient injuries linked to a contracted anesthesiologist at a cataract surgery center, this news article describes how factors such as production pressure and insufficient assessment of contract anesthesiologists' qualifications can contribute to adverse events in outpatient surgery.
What price must we pay for safety? Excessive cost of EPINEPHrine auto-injectors leads to error-prone use of ampuls or vials and unprepared consumers.
ISMP Medication Safety Alert! Acute Care Edition. August 11, 2016;21:1-3.
Landro L. Wall Street Journal. August. 8, 2016.
First-year residents may be reluctant to ask for assistance due to factors such as peer pressure to demonstrate competency. This newspaper article reports on one hospital's strategy to enhance communication among residents and attendings, which encourages residents to ask questions of senior clinicians who are coached to welcome learning conversations.
Ghaferi AA, Myers C, Sutcliffe KM, Pronovost PJ. Harv Bus Rev. July/August 2016;94.
Achieving high reliability is a recognized goal for health care organizations. Reviewing current technical and standardization enhancements to augment quality and safety in surgery, this article explores how implementing high reliability concepts could further improve safety in surgical care over time.
ISMP National Vaccine Errors Reporting Program: one in three vaccine errors associated with age-related factors.
ISMP Medication Safety Alert! Acute Care Edition. July 28, 2016;21:1-6.
Vaccine errors can hinder immunization efforts in the United States. Summarizing nearly 4 years of data submitted to the ISMP Vaccine Errors Reporting Program, this newsletter article highlights age-related factors that surfaced in the analysis and recommends strategies for improvement such as patient education and age verification.
Rau J. National Public Radio. July 27, 2016.
Although quality rating systems have yet to receive approval across the health care industry, they still serve as a way for consumers to select hospitals and providers. The developers of rating services continue to refine metrics to hone their effectiveness. This news article reports on the latest set of ratings from the Hospital Compare program and concerns associated with the results.
ISMP Medication Safety Alert! Acute Care Edition. July 14, 2016;21:1-6.
Patients and clinicians can make medication administration mistakes when new drug delivery mechanisms are introduced. This newsletter article reviews common errors associated with the use of inhalers and offers recommendations for patients, nurses, respiratory therapists, pharmacists, and health care organizations to educate patients on the use of these medications.
Frakt A. New York Times. July 11, 2016.
Patients are increasingly using online symptom checkers for medical information and health care recommendations. This newspaper article reports on various health information applications that provide triage advice to patients and points out that physicians have significantly lower rates of diagnostic errors.