Narrow Results Clear All
- Communication Improvement 4
- Culture of Safety 2
- Education and Training 4
- Error Reporting and Analysis 2
- Human Factors Engineering 2
- Legal and Policy Approaches
- Logistical Approaches 2
- Quality Improvement Strategies 2
- Technologic Approaches
- Diagnostic Errors 1
- Discontinuities, Gaps, and Hand-Off Problems 1
- Medical Complications 1
- Medication Errors/Preventable Adverse Drug Events 4
- Overtreatment 1
- Psychological and Social Complications 2
- Surgical Complications 1
- Family Members and Caregivers 1
- Health Care Executives and Administrators 6
- Health Care Providers 8
- Non-Health Care Professionals 6
- Patients 2
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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 Karen Frush, MD, Errors in the Media and Organizational Change, May 2005
In February 2003, 17-year-old Jessica Santillan died at Duke University Medical Center due to a mismatched heart-lung transplantation. As with the Dana-Farber experience, the death made headlines around the world and devastated the leaders and providers at...
Perspectives on Safety > Perspective
with commentary by Deborah Woodcock, MS, MBA; Robby Bergstrom, Safety of Medical Scribes, August 2019
This piece explores the role medical scribes play in health care, how to implement and evaluate a scribe program, and recommendations to reduce variations in scribe practice.
Perspectives on Safety > Interview
National Organizations in Safety, April 2014
Dr. Gandhi is President of the National Patient Safety Foundation and Associate Professor of Medicine at Harvard Medical School. We spoke with her about NPSF's evolving role in enhancing health care at a national level.
Urbina I, Nixon R. New York Times. March 30, 2007;National Desk section:1.
This article reports on the inconsistent use of the Department of Defense electronic medical records system and how this has led to medical errors and delays in care for US veterans.
Woodcliff Lake, NJ: Drug Topics; 2007.
This podcast features a panel discussion on prescription drug errors with pharmacy experts, including Michael Cohen.
ISMP Medication Safety Alert! Acute Care Edition. September 6, 2007;12:1-4.
This article analyzes a lethal error involving TPN (total parenteral nutrition), in which dosing and compounding were based on incorrect order entry, and provides recommendations to prevent similar errors.
ISMP Medication Safety Alert! Acute Care Edition. July 3, 2008;13:1-3.
This article reports on the potentially fatal error of administering epidural medications intravenously and provides guidelines to safeguard against such epidural–IV route mix-ups.
Journal Article > Study
Sharif I, Tse J. Pediatrics. 2010;125:960-965.
Misunderstanding prescription drug labels is a recognized source of errors in ambulatory care. Low health literacy places patients at higher risk, and language barriers may also contribute to preventable medication errors, as illustrated vividly in an AHRQ WebM&M commentary. A prior study found that translated drug labels are available in many pharmacies, but this study found that Spanish-language labels generated by commercial translation systems are disturbingly inaccurate. Half of the labels contained at least one error, and the authors document examples of incomplete or inaccurate translations that could lead to serious patient harm (for example, "once a day" mistranslated as "eleven times per day"). A prior study also found that Spanish-speaking patients may be at higher risk of experiencing errors while hospitalized.
Journal Article > Commentary
Judson TJ, Press MJ, Detsky AS. Healthc (Amst.). 2019;7:4-6.
Health care is working to provide high-value care and prevent overuse while ensuring patient safety. This commentary highlights the importance of educational initiatives, mentors, and use of clinical decision support to help clinicians determine what amount of care is appropriate for a given clinical situation.
Schulte F, Fry E. Kaiser Health News, Fortune Magazine. March 18, 2019.
Despite years of investment and government support, electronic health records (EHR) continue to face challenges as a patient safety strategy. This news article outlines the unintended consequences of EHR implementation, including patient harm linked to software glitches and user errors, fraudulent behavior (upcoding), interoperability problems, clinician burnout due to poorly designed digital health records, and lack of industry transparency.