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- Study 2
- Legislation/Regulation 1
- Newspaper/Magazine Article
- Special or Theme Issue 12
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Communication between Providers
- Sbar 2
- Communication between Providers 115
- Culture of Safety 75
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- Simulators 13
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Error Reporting and Analysis
- Error Reporting 134
Human Factors Engineering
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Quality Improvement Strategies
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- Alert fatigue 3
- Device-related Complications 51
- Diagnostic Errors 98
- Discontinuities, Gaps, and Hand-Off Problems 74
- Drug shortages 10
- Failure to rescue 3
- Fatigue and Sleep Deprivation 13
- Identification Errors 40
- Interruptions and distractions 8
- Delirium 1
- Medication Errors/Preventable Adverse Drug Events 167
- MRI safety 4
- Nonsurgical Procedural Complications 22
- Overtreatment 6
- Psychological and Social Complications 63
- Second victims 8
- Surgical Complications 138
- Transfusion Complications 4
- Ambulatory Care 75
- Operating Room 101
- General Hospitals 196
- Long-Term Care 14
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- Internal Medicine 313
- Nursing 36
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- Health Care Executives and Administrators 413
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United States of America
United States Federal Government
- Department of Health and Human Services (HHS) 19
- United States Federal Government 24
Search results for "Newspaper/Magazine Article"
- Newspaper/Magazine Article
Rein L. Washington Post. August 30, 2019.
ISMP Medication Safety Alert! Acute Care Edition. August 29, 2019;24.
Mistakes in the administration of intravenous (IV) medications can result in patient harm. Analyzing data from 243 health care facilities regarding the quality of IV push practices in the field, this newsletter article reports adoption of practices such as the use of a new syringe and needle for every IV push injection and outlines 10 best practices to consider for improvement, including the routine supply of IV push medications in ready-to-administer containers and reporting to external bodies to enhance learning.
Frakt A. New York Times. August 26, 2019.
The slow adoption of improvement innovations is a persistent challenge to high-quality and safe patient care. This newspaper article raises concerns about how common treatments are recommended despite insufficient evidence regarding their effectiveness and provides examples of how this problem can result in harm, such as the previous physician belief that opioids were not addictive. Reassessment of science can improve safety and reduce the unintended consequences of ineffective treatments.
Armstrong D. ProPublica. August 23, 2019.
R3 Report. August 21, 2019;24:1-6.
Maternal safety in the United States is gaining momentum as a system-level patient safety concern. This report reviews the new Joint Commission Provision of Care, Treatment, and Services (PC) standards developed to improve the reliability of maternal care. Actions for improvement include patient risk assessment for conditions at admission and role-specific education for staff and providers who treat maternal patients regarding hemorrhage processes and procedures.
Appleby J, Lucas E. Kaiser Health News. August 14, 2019.
Wiley F. Drug Topics. August 2019;1633:16-18.
High-alert medications have the potential to cause serious patient harm if not administered correctly. Reporting on challenges to medication safety in the context of home, hospital, and cancer care, this news article recommends patient and health care professional education and support for collaboration with pharmacists as avenues for improvement.
Panner M. Forbes. August 12, 2019.
Diagnostic errors can result in harm across the spectrum of practice. Discussing cognitive and system factors in radiology that contribute to diagnostic mistakes, this magazine article recommends ways to reduce risk of errors, including peer review of practice, structured reporting, and artificial intelligence–enabled decision support.
Whitaker P. New Statesman. August 2, 2019;148:38-43.
Artificial intelligence (AI) and advanced computing technologies can enhance clinical decision-making. Exploring the strengths and weaknesses of artificial intelligence, this news article cautions against the wide deployment of AI until robust evaluation and implementation strategies are in place to enhance system reliability. A recent PSNet perspective discussed emerging safety issues in the use of artificial intelligence.
Partnering with families and patient advocates: another line of defense in adverse event surveillance.
ISMP Medication Safety Alert! Acute Care Edition. August 1, 2019;24.
Having family members or patient advocates present during hospitalizations can help prevent errors. This newsletter article suggests that utilizing this risk prevention strategy in peripheral care areas such as radiology and other testing units could also prevent patient harm. Recommendations to ensure success of this approach include communicating with advocates, encouraging them to speak up, and activating a rapid response to patient deterioration.
Colino S. Fam Circle. August 2019;132:66,69.
Patients and families can play a role in ensuring care is effective and safe. This news article recommends ways for patients to reduce risk of errors during a hospitalization, including using a patient portal to identify mistakes, asking questions, bringing an advocate, and working with hospitalists as key care partners.
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.
ISMP Medication Safety Alert! Acute Care Edition. June 6, 2019;24.
Butcher L. Managed Care. June 2019;28:37-39.
Inconsistent patient name entry practices in electronic health records can contribute to wrong-patient errors. This magazine article reports on the complex nature of addressing patient-matching discrepancies as an economic, privacy, and technical problem. Improvement strategies include the development and adoption of a national identification program and biometric technology. A WebM&M commentary discussed problems associated with name similarities in the electronic patient record.
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.
Ross C. STAT. May 13, 2019.
Nuisance alarms, interruptions, and insufficient staff availability can hinder effective monitoring and response to acute patient deterioration. This news article reports on how hospital logistics centers are working toward utilizing artificial intelligence to improve clinician response to alarms by proactively identifying hospitalized patients at the highest risk for heart failure to trigger emergency response teams when their condition rapidly declines.
CDC Vital Signs. May 7, 2019.
Maternal morbidity and mortality is a worldwide patient safety problem. This analysis describes the prevalence of pregnancy-related death and areas of concern during pregnancy, at delivery, and up to a year postpartum. It reports that 60% of these deaths are preventable and provides suggestions for families, clinicians, and systems to reduce risks.
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.