Narrow Results Clear All
- Error Reporting and Analysis 4
- Human Factors Engineering 1
- Legal and Policy Approaches 3
- Quality Improvement Strategies 2
- Research Directions 1
Search results for ""
Legislation/Regulation > Sentinel Event Alerts
The Joint Commission. Sentinel Event Alert. December 20, 2004;(33):1-2.
Patient-controlled analgesia (PCA) is a recognized method of controlling pain when administered by credentialed practitioners. However, serious adverse events can result when unauthorized family members, caregivers, or clinicians administer the analgesia for the patient "by proxy." The Joint Commission summarizes the experience of reported PCA incidents and makes recommendations to minimize them.
Journal Article > Study
Evaluation of patient and family outpatient complaints as a strategy to prioritize efforts to improve cancer care delivery.
Mack JW, Jacobson J, Frank D, et al. Jt Comm J Qual Patient Saf. 2017;43:498-507.
Previous research has established that patient complaints can shed light on patient safety concerns. This analysis of 266 patient complaints in cancer care found that more than 40% were interpersonal in nature, whereas 11% were related to quality and safety. The authors suggest ongoing, systematic analysis of patient complaints in order to identify suboptimal care.
Journal Article > Study
Jalal H, Buchanich JM, Roberts MS, Balmert LC, Zhang K, Burke DS. Science. 2018;361:1184.
Opioid overdose deaths remain a threat to patient safety. Information about how overdose deaths are nationally distributed is critical to inform prevention efforts. This robust analysis examined all drug overdose deaths in the United States over a 38-year period. Drug overdoses began increasing exponentially long before the opioid prescribing boom in the mid-1990s and continue to rise in this way. Demographically distinct subepidemics of prescription opioid, synthetic opioid, and stimulant use all contribute to drug overdose deaths as a whole. The authors speculate about what factors other than opioid prescribing might drive escalating substance use-related deaths. An Annual Perspective and a PSNet perspective provide further insights into how safety efforts can reduce opioid-related harm.
Mohr H, Weiss M. Associated Press. November 27, 2018.
Dembosky A. All Things Considered and KQED. January 23, 2019.
Policy, practice, and communication strategies have been implemented in an effort to stem the opioid crisis and prescribing activities that contribute to misuse. This news article and accompanying webcast discuss an initiative in California that sends letters to prescribers whose patients have died due to opioid overdose. The piece outlines unintended consequences associated with the practice, including clinician reluctance to prescribe opioids for pain. An Annual Perspective discussed the patient safety aspects of the opioid epidemic.
Dickson EJ. Rolling Stone. March 9, 2019.
Unintended consequences of restrictions enacted to combat the opioid crisis are a concern for patients and prescribers. This magazine article reports on an effort to raise awareness of the potential for patient harm due to lack of legitimate access to opioids for chronic pain as a result of the 2016 CDC opioid prescribing guidelines.