Narrow Results Clear All
- Communication between Providers 31
- Culture of Safety 16
- Education and Training 20
- Error Reporting and Analysis 38
Human Factors Engineering
- Checklists 19
- Legal and Policy Approaches 41
- Logistical Approaches 5
- Quality Improvement Strategies 29
- Specialization of Care 3
- Teamwork 15
- Technologic Approaches 17
- Transparency and Accountability 5
- Device-related Complications 6
- Diagnostic Errors 2
- Discontinuities, Gaps, and Hand-Off Problems 9
- Drug shortages 1
- Fatigue and Sleep Deprivation 2
- Identification Errors 22
- Interruptions and distractions 2
- Medical Complications 10
- Medication Errors/Preventable Adverse Drug Events 9
- Nonsurgical Procedural Complications 3
- Psychological and Social Complications 6
- Surgical Complications 119
- Transfusion Complications 1
- Internal Medicine 12
- Nursing 5
- Pharmacy 3
- Family Members and Caregivers 5
- Health Care Executives and Administrators 47
Health Care Providers
- Nurses 14
- Physicians 25
- Non-Health Care Professionals 19
- Patients 89
Search results for "Newspaper/Magazine Article"
- Newspaper/Magazine Article
Joseph R, Harry E. Medical Economics. June 27, 2019.
Multitasking can negatively affect cognitive load and diminish safety. This magazine article reports on how multitasking can contribute to surgeon fatigue, burnout, and decreased task completion in the perioperative environment. Checklists to automate workflow and limiting the number of patient charts that can be open at one time can help reduce extraneous cognitive load.
Appleby J, Lucas E. Kaiser Health News. June 21, 2019.
Gabler E. New York Times. May 31, 2019.
Pediatric cardiac surgery is highly technical and risky. This newspaper article reports on a poorly performing pediatric cardiac surgery program, concerns raised by staff, and insufficient response from organizational leadership. Lack of data transparency, insufficient resources, and limited program capabilities to support a complex program contributed to poor outcomes for pediatric patients.
Hilton K, Anderson A. Harv Bus Rev. May 20, 2019.
This commentary describes how one health system worked to combat resistance to change associated with implementation of a checklist initiative. The success of the program was built on empowering team members to drive the process, clinician motivation to provide safe care, and engaging leadership. A PSNet interview with Lucian Leape discussed surgical safety checklists.
Span P. New York Times. February 1, 2019.
Cognitive and functional decline can occur as individuals age. Concerns have been raised regarding the need to assess skills of aging physicians. This newspaper article reports on the implementation of mandatory evaluation programs to assess competencies of older surgeons and the profession's response to them.
Hixenbaugh M, Ornstein C. Houston Chronicle and Propublica.
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.
Cierniak KH, Gaunt MJ, Grissinger M. PA-PSRS. Patient Saf Advis. 2018;15(4).
The operating room environment harbors particular patient safety hazards. Drawing from 1137 perioperative medication error reports submitted over a 1-year period, this analysis found that more than half of the recorded incidents reached the patient and the majority of those stemmed from communication breakdowns during transitions or handoffs. The authors provide recommendations to reduce risks of error, including using barcode medication administration, standardizing handoff procedures, and stocking prefilled syringes.
McGrory K, Bedi N. Tampa Bay Times. November 28, 2018.
Biel L. ProPublica. October 2, 2018.
This news article reports on systemic weaknesses that enabled a surgeon with poor skills to continue to perform procedures after numerous surgical errors that resulted in patient harm. A past PSNet perspective explored the risk of recurring medicolegal events among providers who have received unsolicited patient complaints, faced disciplinary actions by medical boards, or accumulated malpractice claims.
Jewett C, Alesia M. Kaiser Health News. August 9, 2018.
High-profile failures during office-based procedures have raised awareness of the potential safety hazards of surgery centers and the need for improved oversight. This news article reports on safety events in ambulatory surgical centers and insufficiencies in incident reporting and analysis. Enhanced transparency regarding those failures can enable informed patient decision-making when choosing care providers.
Bruley ME, Arnold TV, Finley E, Deutsch ES, Treadwell JR. PA-PSRS Pa Patient Saf Advis. June 2018;15.
Although surgical fires are considered never events, they continue to occur. This article reports findings from an analysis of 28 operating room fire incidents submitted over a 5-year period to the Pennsylvania Patient Safety Reporting System. Although incidence of surgical fires has significantly decreased since earlier reporting periods, half of the reported events resulted in patient harm. A past WebM&M commentary discussed surgical fires and how to prevent them.
Mukherjee S. New York Times Magazine. May 9, 2018.
Checklists can coordinate action and communication to augment safety, but human and system factors may hinder their effectiveness. This magazine article reports on how the checklist phenomenon evolved into a global patient safety effort and spotlights the impact of human behavior on reliable implementation of checklist programs in different care environments.
Meyer TA, McAllister RK. Pharmacy Practice News. March 19, 2018.
Perioperative adverse drug events are common and understudied. Reporting on the complexity of medication administration during surgery, this news article reviews strategies to reduce risks of surgical adverse drug events. Specific tactics discussed include proactive problem identification, medication reconciliation, high-alert medication process vigilance, verbal order reduction, and information technology optimization.
Hamilton WL. Patient Saf Qual Healthc. July 31, 2017.
Miscommunication during care transitions can contribute to medical errors. This article discusses how handoff communication tools can help to improve reliability of information transfer associated with anesthesia practice. The authors emphasize the importance of standardizing the process of perioperative data collection.
Boodman SG. Kaiser Health News. July 12, 2017.
Baker M. Seattle Times. February 10, 2017.
Reporting on an incident involving a patient who died after a surgery, this news article discusses potential contributing factors in the incident such as concurrent surgeries and failure to consider patient and family concerns. A past WebM&M commentary highlighted the importance of listening to families when they advocate for patients in the hospital.
ISMP Medication Safety Alert! Acute Care Edition. December 1, 2016;21:1-3.
Accidental administration of irrigation solutions are a wrong-route error that can result in harm. This newsletter article reviews factors that contribute to these incidents in the operating room, such as unlabeled solutions, look-alike labeling, and line connection issues. Recommendations to reduce risks include communicating during transitions, safe storage, and immediate labeling.
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.
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.
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.