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- WebM&M Cases 3
- Perspectives on Safety 2
- Review 1
- Study 4
- Audiovisual 12
- Book/Report 5
- Newspaper/Magazine Article 51
- Toolkit 1
- Web Resource 13
- Press Release/Announcement 5
- Communication Improvement 28
- Culture of Safety 5
- Education and Training 16
- Error Reporting and Analysis 18
- Human Factors Engineering 17
- Legal and Policy Approaches 30
- Logistical Approaches 8
- Policies and Operations 1
- Quality Improvement Strategies 18
- Research Directions 1
- Specialization of Care 1
- Teamwork 1
- Technologic Approaches 14
- Transparency and Accountability 1
- Alert fatigue 1
- Device-related Complications 12
- Diagnostic Errors 8
- Discontinuities, Gaps, and Hand-Off Problems 9
- Drug shortages 2
- Failure to rescue 1
- Fatigue and Sleep Deprivation 3
- Identification Errors 3
- Medical Complications 10
- Medication Errors/Preventable Adverse Drug Events 15
- Nonsurgical Procedural Complications 3
- Overtreatment 2
- Psychological and Social Complications 15
- Surgical Complications 5
- Transfusion Complications 1
- Internal Medicine 23
- Nursing 6
- Pharmacy 10
- Family Members and Caregivers 9
- Health Care Executives and Administrators 30
Health Care Providers
- Nurses 5
- Physicians 11
Non-Health Care Professionals
- Media 3
Search results for ""
Serious adverse events from accidental ingestion by children of over-the-counter eye drops and nasal sprays.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; October 25, 2012.
This announcement raises awareness of risks associated with children accidentally ingesting over-the-counter eye drops and nasal sprays.
Thomas K. New York Times. November 17, 2012:A1.
This newspaper article reports on the concerns of patients and health care workers associated with the continuing drug shortages in the United States.
Tools/Toolkit > Fact Sheet/FAQs
Horsham, PA: Institute for Safe Medication Practices; 2018.
This set of leaflets provides patients with information about taking high-alert medications safely.
Tools/Toolkit > Fact Sheet/FAQs
Consumer Updates. Silver Spring, MD: US Food and Drug Administration; December 12, 2012.
Highlighting concerns associated with patients' use of medical devices at home, such as difficulty understanding instructions, this article offers tips for consumers to help reduce risks.
Kowalczyk L. Boston Globe. April 9, 2013.
This newspaper article describes how one hospital has fostered open communication about medical errors through a monthly newsletter that recounts mistakes in an effort to prevent them from recurring. Reports in the newsletter also solicit the involved patient's perspective.
Gunderman R. The Atlantic. June 5, 2013.
This magazine article highlights the drawbacks of amassing information in electronic medical records, in that it may negatively influence real communication or clinicians' genuine understanding of the patient.
Tools/Toolkit > Fact Sheet/FAQs
Consumer Updates. Silver Spring, MD: US Food and Drug Administration; July 16, 2013.
This information sheet covers how misuse of medical devices in children may contribute to adverse events.
Ofri D. New York Times. July 18, 2013.
In this newspaper piece, a physician describes the pervasive issue of disrespect in health care, its connection to patient safety, and clinicians' responsibility to model respectful behavior.
Rosenbaum L. The New Yorker: Elements. August 20, 2013.
This magazine article relates the risks and benefits associated with the 2003 resident work hour limits.
Journal Article > Review
Promoting engagement by patients and families to reduce adverse events in acute care settings: a systematic review.
Berger Z, Flickinger TE, Pfoh E, Martinez KA, Dy SM. BMJ Qual Saf. 2014;23:548-555.
Patient engagement is touted as an important tool for detecting adverse events and ensuring safety. This systematic review found that more high-quality evidence is needed to inform practical application of patient engagement programs.
Knox R. Morning Edition. National Public Radio. January 27, 2014.
Yurkiewicz I. Aeon Magazine. January 29, 2014.
Disruptive behavior is a well-known and pervasive issue in health care. Describing disrespectful behaviors that clinicians face, such as sarcasm and intimidation, this magazine article emphasizes how they can hinder effective interactions and communication to reduce patient safety.
NPSF Lucian Leape Institute Roundtable on Consumer Engagement in Patient Safety. Boston, MA: National Patient Safety Foundation; March 2014.
The National Patient Safety Foundation's Lucian Leape Institute recently convened two roundtables to discuss engaging patients and families in improving patient safety. This report describes the current landscape of patient engagement efforts, along with the potential benefits and challenges. To facilitate more productive partnerships in ensuring safety, the group provides recommendations and checklists for health care leaders, clinicians, patients, families, and policymakers. They advocate for patients to be equal partners in organizational and clinician care improvement activities. Patients are encouraged to feel empowered to ask questions and to actively participate in their care plans. A recent AHRQ WebM&M perspective explores the role of patient engagement in safety.
Rabin RC, Kaiser Health News. Washington Post. March 31, 2014.
This newspaper article reports on factors contributing to physician burnout and describes obstacles to resolving it. Burnout in the primary care setting was often related to business aspects such as insurance payments, managing staff, and increased oversight. Physician happiness was found to be tied to patient satisfaction, and electronic medical record use was perceived to impede meaningful interaction.
Catalanello R. The Times-Picayune. April 15, 2014.
Chen PW. New York Times. April 24, 2014.
Examining whether medical school graduates are equipped to provide direct patient care in the beginning of their internships, this newspaper article reports how educators have collaborated to identify and integrate competencies, such as assertiveness and time management, to augment the safety of this transition.
Lichtblau E. New York Times. June 15, 2014.
This newspaper article reports how a "culture of silence" at Veterans Affairs hospitals discouraged staff from speaking up about safety and quality concerns related to the use of inaccurate wait time data.
Silver Spring, MD: US Food and Drug Administration. Office of Women's Health and National Association of Chain Drug Stores.
This toolkit offers tips for patients to prevent adverse drug events and provides a way to record important medication information such as a list of allergies, prescriptions, dosages, and conditions being treated.
Chicago, IL: American Hospital Association Physician Leadership Forum; July 2014.
Kimmelman M. New York Times. August 21, 2014.
This newspaper article reports on how design solutions for hospitals, such as rooms modeled for single patients with sinks placed in plain sight, handrails linking the bedside to the bathroom, and large windows with natural light and an outdoor view, can augment patient satisfaction and safety.
Olson J. Star Tribune. February 9, 2015.
Rice S. Mod Healthc. 2014;44:16-18, 20.
Language barriers can lead to misunderstandings that increase risks of error. This magazine article highlights the frequent reliance on families, friends, and other nonprofessionals as translators in medical settings and discusses how lack of standards and insufficient reporting of errors related to interpreters, along with challenges to implementing programs, hinder progress in improving communication with non-English speaking patients.
Journal Article > Study
Family participation during intensive care unit rounds: goals and expectations of parents and health care providers in a tertiary pediatric intensive care unit.
Stickney CA, Ziniel SI, Brett MS, Truog RD. J Pediatr. 2014;165:1245-1251.
In this study, health care providers and parents of children in a pediatric intensive care unit described their perceptions of family involvement in morning rounds. Although parents were overwhelmingly enthusiastic about being included in rounds, providers expressed some concerns and potential drawbacks, such as the avoidance of discussing uncomfortable topics due to presence of family.
Langewiesche W. Vanity Fair. October 2014.
This magazine article provides a breakdown of the failures that contributed to an airplane crash, including how increasing automation in piloting airplanes can diminish human performance, the reluctance to speak up due to hierarchy, lack of preparedness in the face of malfunctioning technology, and poor decision-making. Many of these concerns have been raised in relation to health care safety.
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.
Journal Article > Study
Shiffman S, Cotton H, Jessurun C, Rohay JM, Sembower MA. J Am Pharm Assoc (2003). 2016;56:495-503.
Poor health literacy is associated with the misunderstanding of medication labels, which can lead to adverse drug events. This study sought to assess how adding an acetaminophen icon to the labels of acetaminophen-containing medications affects consumers' ability to avoid unintentional overdose, which is known to cause liver damage. Investigators found that presence of the icon reduced the likelihood of medication errors by 53%, and they concluded that the icon may particularly benefit those with lower health literacy. A past WebM&M commentary discussed a case of liver injury caused by incorrect dosing of acetaminophen.
Landro L. Wall Street Journal. August. 8, 2016.
First-year residents may be reluctant to ask for assistance due to factors such as peer pressure to demonstrate competency. This newspaper article reports on one hospital's strategy to enhance communication among residents and attendings, which encourages residents to ask questions of senior clinicians who are coached to welcome learning conversations.
FDA Safety Communication: use caution with implanted pumps for intrathecal administration of medicines for pain management.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; November 14, 2018.
This safety announcement raises awareness of pump failures, dosing errors, and other potential safety issues associated with implanted pumps. Recommendations to enhance safety include review of medication labeling to select appropriate medicines and concentrations as well as open discussions with patients about risks associated with pump and medication options.
DeMarco P. Globe Magazine. November 3, 2018.
This magazine article reports on the preventable death of a patient during an acute asthma attack. Written by the patient's husband, the article outlines the failures that led to her death despite the fact that she was at the door of a hospital emergency department and on the phone with an emergency dispatcher. Factors discussed include overreliance on poorly functioning technology, communication failures, and lack of fail-safes.
Journal Article > Study
Patient groups, clinicians and healthcare professionals agree—all test results need to be seen, understood and followed up.
Dahm MR, Georgiou A, Herkes R, et al. Diagnosis (Berl). 2018;5:215-222.
Inadequate test result follow-up places patients at risk of delayed diagnosis, especially in the ambulatory setting. Diverse stakeholders in Australia established an agenda for enhancing test result management, which included better governance, improved use of technology, and consistent patient engagement. A WebM&M commentary explored two incidents where poor test result follow-up led to patient harm.
Gawande A. New Yorker. November 12, 2018.
In this magazine article, Atul Gawande describes a range of frustrations physicians experience as digitization becomes more widespread in health care. He elaborates upon several elements of electronic health record use that can degrade care processes and create conditions for errors, such as burnout, lack of patient-centeredness, and alert fatigue.
Mohr H, Weiss M. Associated Press. November 27, 2018.
FDA identifies harm reported from sudden discontinuation of opioid pain medicines and requires label changes to guide prescribers on gradual, individualized tapering.
Silver Spring, MD: US Food and Drug Administration; April 9, 2019.
Efforts to address the opioid epidemic range from regulation to changes in pain management. This safety announcement raises awareness of potential harms associated with rapidly decreasing the dose of or discontinuing opioids for patients who may be physically dependent on the medication. It also announces a requirement regarding changes to prescribing information for opioids to provide expanded guidance on how to safely taper doses. Health care providers should discuss tapering plans with patients and provide ongoing monitoring and support.
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.
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.
Journal Article > Study
Shen C, Nguyen M, Gregor A, Isaza G, Beattie A. JAMA Ophthalmol. 2019;137:690-692.
This study entered 42 validated clinical vignettes for eye diseases into an online symptom checker. As with prior studies, the performance of the online symptom checker in producing the correct diagnosis was suboptimal. The authors suggest that current performance of symptom checkers is not sufficient for timely and accurate diagnosis of ophthalmologic conditions.
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.
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.