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- Patient Safety Primers 1
- WebM&M Cases 5
- Perspectives on Safety 4
- Commentary 17
- Review 2
- Study 37
- Slideset 1
- Book/Report 29
- Legislation/Regulation 2
- Newspaper/Magazine Article 85
- Special or Theme Issue 2
- Glossary 1
- Toolkit 11
- Web Resource 40
- Meeting/Conference 4
- Press Release/Announcement 5
- Communication between Providers 22
- Culture of Safety 11
- Education and Training 72
Error Reporting and Analysis
- Error Reporting 42
- Human Factors Engineering 17
- Legal and Policy Approaches 24
- Logistical Approaches 5
- Quality Improvement Strategies 54
- Research Directions 1
- Specialization of Care 7
- Teamwork 4
- Clinical Information Systems 16
- Transparency and Accountability 3
- Device-related Complications 5
- Diagnostic Errors 21
- Discontinuities, Gaps, and Hand-Off Problems 24
- Failure to rescue 1
- Fatigue and Sleep Deprivation 2
- Identification Errors 12
- Medical Complications 18
- Medication Errors/Preventable Adverse Drug Events 36
- Nonsurgical Procedural Complications 1
- Psychological and Social Complications 23
- Surgical Complications 22
- Transfusion Complications 1
- Internal Medicine 38
- Pediatrics 16
- Nursing 5
- Palliative Care 2
- Pharmacy 35
- Family Members and Caregivers 47
- Health Care Executives and Administrators 85
Health Care Providers
- Nurses 8
- Pharmacists 12
- Physicians 32
Non-Health Care Professionals
- Media 2
- Australia and New Zealand 6
- Europe 15
- Canada 8
- United States of America 202
Search results for ""
Colino S. Fam Circle. August 2019;132:66,69.
Patients and families can play a role in ensuring care is effective and safe. This news article recommends ways for patients to reduce risk of errors during a hospitalization, including using a patient portal to identify mistakes, asking questions, bringing an advocate, and working with hospitalists as key care partners.
Journal Article > Study
DesRoches CM, Bell SK, Dong Z, et al. Ann Intern Med. 2019 May 28; [Epub ahead of print].
Legislation/Regulation > Colorado Legislation
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.
Canadian Patient Safety Institute and Health Standards Organization.
This draft 5-year framework aims to guide the activities in Canada to focus action, resources, and policy development on supporting care improvement. The document is structured around five goals: people-centered care, safe care, accessible care, appropriate care, and continuous care. The authors invited Canadian patients, families, clinicians, organization leaders, and policymakers to provide input on the material to ensure its applicability across the country.
Journal Article > Study
Making infection prevention and control everyone's business? Hospital staff views on patient involvement.
Sutton E, Brewster L, Tarrant C. Health Expect. 2019 Feb 17; [Epub ahead of print].
Interviews with frontline hospital staff and executive leaders revealed that they were generally supportive of engaging families and patients to promote infection prevention in the clinical setting when using a collaborative approach. Staff identified certain challenges including concerns related to the extent of responsibility patients and families should bear with regard to infection prevention as well as risks to infection control posed by patients themselves.
FDA Safety Communication: caution when using robotically-assisted surgical devices in women's health including mastectomy and other cancer-related surgeries.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; February 28, 2019.
This announcement seeks to raise awareness of the potential risks associated with the use of robotic-assisted surgical devices in mastectomies or cancer-related care. Recommendations for patients who may seek to have robotically assisted surgery include asking about their surgeon's experience with these procedures and discussing benefits, risks, and alternatives regarding available treatment options with their health care provider. Suggestions for health care providers include completing specialized training on procedures they perform. A WebM&M commentary described the challenges and benefits associated with robotic surgery.
Patient Safety Primers
Anyone can find it challenging to understand medical terms, and millions of Americans have trouble understanding and acting upon health information. The mismatch between individuals' health literacy skills and the complexity of health information and health care tasks involved in managing health has implications on patient safety.
Journal Article > Study
Consumers' perspectives on their involvement in recognizing and responding to patient deterioration—developing a model for consumer reporting.
King L, Peacock G, Crotty M, Clark R. Health Expect. 2019;22:385-395.
Canadian Patient Safety Institute. October 2018.
Graham J. Kaiser Health News. November 21, 2018.
Patients can identify errors in their medical records that health care providers may not recognize. This news article highlights the importance of patients correcting seemingly simple mistakes such as name misspellings and phone numbers as these errors can contribute to situations that result in patient harm.
FDA Safety Communication: use caution with implanted pumps for intrathecal administration of medicines for pain management.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; November 14, 2018.
This safety announcement raises awareness of pump failures, dosing errors, and other potential safety issues associated with implanted pumps. Recommendations to enhance safety include review of medication labeling to select appropriate medicines and concentrations as well as open discussions with patients about risks associated with pump and medication options.
Journal Article > Study
Patient groups, clinicians and healthcare professionals agree—all test results need to be seen, understood and followed up.
Dahm MR, Georgiou A, Herkes R, et al. Diagnosis (Berl). 2018;5:215-222.
Inadequate test result follow-up places patients at risk of delayed diagnosis, especially in the ambulatory setting. Diverse stakeholders in Australia established an agenda for enhancing test result management, which included better governance, improved use of technology, and consistent patient engagement. A WebM&M commentary explored two incidents where poor test result follow-up led to patient harm.
Peskin SM. New York Times. October 4, 2018.
Error disclosures are difficult but important conversations that can have negative consequences for patients, clinicians, and organizations, even when they are done appropriately. This newspaper article offers insights from a doctor who experienced both sides of disclosure, as a physician disclosing an error and as a patient whose physician missed a complication, and discusses how to manage relationships once clinical mistakes are recognized.
Journal Article > Commentary
Leistikow I, Huisman F. J Patient Saf Risk Manag. 2018;23:139-141.
Eldred SM. Health Shots. National Public Radio. August 15, 2018.
Using professional interpreters can avert risks of miscommunication due to language barriers between patients and clinicians. This news article discusses how lack of qualified medical interpreters, use of ad hoc interpreters, and poor patient understanding of instructions can contribute to adverse events. A WebM&M commentary explored patient safety issues associated with patient–clinician language differences.
Fetters A. The Atlantic. August 10, 2018.
Women face implicit bias that can affect the safety and effectiveness of their care. Reviewing several high-profile accounts that raised awareness of challenges women experience in health care, this magazine article describes challenges to safe care such as lack of physician attention to patient concerns, misdiagnosis, and preconceptions regarding pain intensity.
Journal Article > Study
Mullen RJ, Curtis LM, O'Conor R, et al. Am J Health Syst Pharm. 2018;75:e213-e220.
Prior research has shown that patients with limited health literacy are at increased risk for misunderstanding the appropriate dosing of acetaminophen, a commonly used nonprescription medication that can cause acute liver failure after an overdose. In this study, researchers examined the risk of nonprescription acetaminophen misuse among 500 English-speaking patients across 4 outpatient clinics. They found that 39% of participants had limited health literacy and 54% had low visual acuity. Both reduced visual acuity and lower health literacy were independent risk factors for dosing errors and for insufficient understanding regarding the simultaneous use of multiple acetaminophen-containing products. An AHRQ Literacy Toolkit is available that provides a business case for interventions, educational tools, and guides for engaging patients in health literacy discussions. A previous WebM&M commentary discussed an incident involving confusion with acetaminophen dosing.
Crouch M. Reader's Digest. April 2018.
Involving patients in their care can help improve safety. This magazine article provides 34 tips from leading patient safety experts to assist patients in this role. Tactics include considering a second opinion, bringing an up-to-date medication list, and repeating information back to providers to reduce misunderstandings.
Lamas D. New York Times. March 27, 2018.
Advance care planning can affect patient safety if the information is unheeded, unavailable, or unread. Reporting on a physician's experience with a patient who nearly received an unwanted intubation due to poor electronic health record data quality and design, this newspaper article describes problems associated with lack of standards for advance care planning documentation and the inability to access advance directives.
Boodman SG. Washington Post. March 26, 2018.
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.