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Cases & Commentaries
- Web M&M
Colin F. Mackenzie, MD; March 2004
Video monitors near the operating room reveal a patient's identity, and gossip spreads about a very private issue.
Perspectives on Safety > Perspective
with commentary by Linda H. Aiken, PhD, RN , Nursing and Patient Safety , July-August 2005
The goal set by the Institute of Medicine (IOM) in 1999 to reduce medical errors by half within 5 years has not been achieved. Opinion polls of consumers and health professionals show that concerns about patient safety remain high. Yet only 16% of hospital...
Journal Article > Commentary
Larsen D, Cole R, Higton P. Nurs Stand. 2007;21:35-40.
By introducing several scenarios that illustrate the effective use of a decision-making tree, the authors emphasize the importance of fair response to medication error at both the individual and system levels.
Journal Article > Study
Painter LM, Dudjak LA, Kidwell KM, Simmons RL, Kidwell RP. J Nurs Care Qual. 2011;4:311-319.
Brown T. New York Times. March 17, 2013:SR5.
Journal Article > Commentary
Development of a professionalism committee approach to address unprofessional medical staff behavior at an academic medical center.
Speck RM, Foster JJ, Mulhern VA, Burke SV, Sullivan PG, Fleisher LA. Jt Comm J Qual Patient Saf. 2014;40:161-167.
Unprofessional behavior can hinder patient safety and create a disruptive work environment for other staff. The Joint Commission requires that organizations have clear processes for detecting and reporting unacceptable behaviors. This commentary describes the development and experience of a Professionalism Committee at the University of Pennsylvania Health System. The committee chair serves as the first point of contact for any behavioral concerns. In this system, the committee chair is a trained psychiatrist, which the authors argue is an important aspect of the program since it allows for early identification of behavioral health issues that could contribute to unprofessionalism. The article includes the specific problems addressed and the referral outcomes of 79 cases over 2 years, along with 3 illustrative case vignettes. A prior AHRQ WebM&M commentary focused on the importance of professionalism in patient safety, and an AHRQ WebM&M perspective reviewed strategies to identify and manage problem behaviors.
Robbins A. Good Housekeeping. May 20, 2016.
Disruptive behaviors are receiving increased attention as a cultural factor that contributes to medical error. Although much of the focus has been on physicians, the presence of bullying among nurses is also a concern. This magazine article explores nurse behaviors such as withholding information, intimidation, and name calling that negatively affect patient safety and nurse retention.