Narrow Results Clear All
- Communication between Providers 25
- Culture of Safety 35
Education and Training
- Students 2
Error Reporting and Analysis
- Never Events 12
- Error Reporting 202
- Human Factors Engineering 41
Legal and Policy Approaches
- Regulation 29
- Logistical Approaches 10
- Policies and Operations 5
- Quality Improvement Strategies 61
- Specialization of Care 7
- Teamwork 8
- Clinical Information Systems 13
- Transparency and Accountability 12
- Device-related Complications 25
- Diagnostic Errors 31
- Discontinuities, Gaps, and Hand-Off Problems 18
- Drug shortages 4
- Failure to rescue 1
- Fatigue and Sleep Deprivation 1
- Identification Errors 14
- Interruptions and distractions 1
- Delirium 1
- Medication Errors/Preventable Adverse Drug Events 64
- MRI safety 2
- Nonsurgical Procedural Complications 13
- Psychological and Social Complications 16
- Second victims 3
- Surgical Complications 44
- Transfusion Complications 2
- Ambulatory Care 29
- General Hospitals 60
- Long-Term Care 8
- Outpatient Surgery 6
- Patient Transport 3
- Psychiatric Facilities 3
- Allied Health Services 2
- Internal Medicine 94
- Pediatrics 14
- Nursing 8
- Palliative Care 1
- Pharmacy 37
- Family Members and Caregivers 12
- Health Care Executives and Administrators 182
Health Care Providers
- Nurses 21
- Pharmacists 21
- Physicians 59
Non-Health Care Professionals
- Media 3
- Patients 155
- Europe 8
- Canada 5
- United States of America 348
Search results for "Newspaper/Magazine Article"
- Newspaper/Magazine Article
- Error Reporting and Analysis
Palmer J. Patient Saf Qual Healthc. May/June 2019.
Organizations must learn from adverse events to prevent similar incidents. Reporting on lessons to be learned from the cascade of failures connected with the preventable death of a patient during an acute asthma attack at the door of a hospital emergency department, this magazine article outlines the importance of effective signage, appropriate security staff placement, and acceptance of the responsibility for failure.
Jewett C. Kaiser Health News. May 3, 2019.
Transparency has been heralded as a cornerstone to improvement in health care. This news article reports on a government alternative summary reporting program that allowed medical device makers to conceal safety events and malfunction reports associated with medical devices. A new program that expands access to information about device-related failures will be put in place.
Quick Safety. April 15, 2019;(48):1-3.
Fatigue, emotional stress, and illness can affect decision-making and lead to misuse of medications. This newsletter article describes the patient safety impacts of drug diversion among health care workers and notes the importance of a culture of constructive reporting to uncover and address this unsafe behavior.
Field C, Finley E, Deutsch ES. PA-PSRS Pa Patient Saf Advis. 2019;16(1).
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.
Park A. Time Magazine. January 24, 2019.
This news article reports on the documentary To Err Is Human, which was produced and directed by the son of patient safety leader Dr. John M. Eisenberg. The film is structured around patient safety advocate Sue Sheridan's experience with diagnostic errors that resulted in harm for both her son and husband. It features a wide range of experts who discuss the impact of error on all involved, the role of culture in facilitating both mistakes and progress, and why continued work in health care safety is needed.
Beck DL. ASH Clinical News. December 1, 2018.
ISMP Medication Safety Alert! Acute Care Edition. November 29, 2018;23:1-6.
Look-alike and sound-alike medications present a recurring threat to patient safety. This newsletter article summarizes an analysis of reported drug name confusion errors. Although incidents seem to have decreased over time, the influx of generic drug names is contributing to the persistence of the problem. Increased federal attention to the issue, provider use of known strategies to improve practice, and pharmaceutical company testing of names to avoid similarities can help reduce drug name confusion.
McGrory K, Bedi N. Tampa Bay Times. November 28, 2018.
Mohr H, Weiss M. Associated Press. November 27, 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.
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.
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.
Young A, Kelly J, Schnaars C, Ungar L. USA Today.
ISMP Medication Safety Alert! Acute Care. July 12, 2018;23:1-4.
Smart pumps are employed throughout health care, but their design can challenge safety. Reporting results of a national survey, this newsletter article outlines how smart pump data is being used to improve compliance and suggests ways organizations can enhance the value of analytics to inform frontline practice improvement. A previous WebM&M commentary discussed a smart infusion pump error that resulted in patient harm.
ISMP Medication Safety Alert! Acute Care Edition. June 14, 2018,23:1-5. June 28, 2018;23:1-4,6,7.
Mistakes in the use of vaccines can have both individual and public health implications. The first article of this series reviews the results from an analysis of reports submitted to a national error reporting system to track vaccine-related errors. The second article offers recommendations to help immunization and vaccination programs address product-, knowledge-, and practice-related factors that contribute to process weaknesses, including training, storage, and labeling strategies.
Kowalczyk L. Boston Globe. May 27, 2018.
Pediatric patients are particularly vulnerable to medication errors. This news article reports on serious medication errors that occurred at Children's Hospital in 2017, the underlying system failures that contributed to the incidents, and challenges to implementing new policies meant to prevent similar errors.
Headley M. Patient Saf Qual Healthc. May/June 2018.
Clinicians can experience emotional stress, guilt, and insecurity after making a mistake. Organizations are increasingly building programs to enable second victims to return to safe and confident practice. This magazine article highlights factors that contribute to success of second victim support programs, such as an established culture of safety, focus on emotional needs rather than skill assessment, and sustained leadership engagement in the program.
O'Loughlin E. New York Times. April 30, 2018.
Large-scale adverse events should lead to system examination and improvement. This newspaper article reports on misread cervical cancer tests that resulted in 208 women receiving false negative results over a 4-year period from a publicly funded smear test program in Ireland and the government inquiry launched in response to this large-scale failure.
ISMP Medication Safety Alert! Acute Care Edition. April 5, 2018;23:1-5.
Smart pumps are considered an important tool to improve medication safety in the hospital environment. This newsletter article summarizes the results of two national surveys on smart infusion pump use to highlight current concerns and challenges to generating improvements. Irrelevant alarms and out-of-date drug libraries were among the problems identified by survey participants.