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- WebM&M Cases 2
- Perspectives on Safety 2
- Review 1
- Study 2
- Audiovisual 8
- Book/Report 4
- Newspaper/Magazine Article 37
- Toolkit 1
- Web Resource 4
- Press Release/Announcement 1
- Communication Improvement 22
- Culture of Safety 5
- Education and Training 7
- Error Reporting and Analysis 13
- Human Factors Engineering 12
- Legal and Policy Approaches 22
- Logistical Approaches 6
- Policies and Operations 1
- Quality Improvement Strategies 14
- Specialization of Care 1
- Teamwork 1
- Technologic Approaches 9
- Transparency and Accountability 1
- Alert fatigue 1
- Device-related Complications 8
- Diagnostic Errors 5
- Discontinuities, Gaps, and Hand-Off Problems 8
- Failure to rescue 1
- Fatigue and Sleep Deprivation 2
- Identification Errors 1
- Medical Complications 10
- Medication Safety 10
- Nonsurgical Procedural Complications 3
- Overtreatment 1
- Psychological and Social Complications 11
- Surgical Complications 5
- Transfusion Complications 1
- Medicine 48
- Nursing 4
- Pharmacy 5
- Family Members and Caregivers 4
- Health Care Executives and Administrators 23
Health Care Providers
- Nurses 4
- Physicians 10
Non-Health Care Professionals
- Media 2
Search results for ""
Cases & Commentaries
- Web M&M
Bryan A. Liang, MD, PhD, JD; May 2004
Understanding that she may lose her life without it, a woman severely injured in a collision rejects a blood transfusion for religious reasons. However, her parents persuade the physicians otherwise, and the woman lives.
Cases & Commentaries
- Web M&M
Glenn Flores, MD; April 2006
With no one to interpret for them and pharmacy instructions printed only in English, nonEnglish-speaking parents give their child a 12.5-fold overdose of a medication.
Perspectives on Safety > Perspective
Organizational Change in the Face of Highly Public Errors—I. The Dana-Farber Cancer Institute Experience
with commentary by James B. Conway; Saul N. Weingart, MD, PhD, Errors in the Media and Organizational Change, May 2005
A decade ago, two tragic medical errors rocked one of the world’s great cancer hospitals, Dana-Farber Cancer Institute (DFCI) in Boston, to its core. The errors led to considerable soul searching and, ultimately, a major change in institutional practices a...
Perspectives on Safety > Interview
The Patient's Role in Safety, March 2007
Sorrel King is the mother of Josie King, who died tragically in 2001 at age 18 months because of medical errors during a hospitalization at Johns Hopkins Hospital. She has subsequently become one of the nation’s foremost patient advocates for safety, forming an influential foundation (the Josie King Foundation) and partnering with Johns Hopkins to promote the field of patient safety around the world.
van Vuuren W. [dissertation]. Eindhoven, The Netherlands: Eindhoven University of Technology; 1998.
This report provides a detailed review of risk management in complex and high-risk organizations. The author focuses on the analysis and categorization of safety-related incidents and their organizational causes.
Meisel Z. Slate. November 8, 2005.
In this article, an emergency medicine physician describes the work environment of emergency medical technicians and paramedics and why it is prone to error.
A Consensus Statement of the Harvard Hospitals. Burlington: Massachusetts Coalition for the Prevention of Medical Errors; 2006.
This consensus paper of the Harvard-affiliated hospitals was prepared by clinicians, risk managers, and patients to provide an in-depth understanding of preventable adverse events, their impact on patients, families, and providers, and how to manage such events. The report provides detailed guidelines based on the premise that all care should be safe and patient-centered and that all actions require full disclosure. In addition to offering recommendations on how to effectively communicate with patients and families, the report discusses support for caregivers and a detailed strategy for institutions to respond to such events in a timely and appropriate fashion. Finally, the comprehensive report offers several appendices that include recommendations and a case study on communicating with patients and families.
Washington, DC: CCM, Inc.; 2006. Crawford-Mason C (producer), Dobyns L (reporter); Management Wisdom Video Series.
This documentary reports on the experiences of a large health care system's success in adopting a systems approach to improving care, reducing costs, and saving lives. The program will air on PBS stations after April 1, 2006; check local stations for dates and times. (Note: This summary is based on information from the producers; a copy of the documentary was not available for preview).
Stout D. New York Times. June 17, 2006;National desk:9.
This article reports on the investigation following the death of New York Times reporter David E. Rosenbaum. The investigation uncovered a range of failures in emergency care and is described in a report available via the link below.
Davies T. Washington Post. September 22, 2006.
This article reports on the deaths of three infants from heparin overdoses and describes how the hospital community has responded to the errors.
Feinmann J. The Independent. November 14, 2006.
This article reports on a husband's investigation into his wife's death following a routine surgery and his subsequent efforts to bring human factors training to National Health Service hospitals.
"Eye to Eye with Katie Couric." CBS News Video. February 6, 2007.
Dr. Berwick, President and CEO of the Institute for Healthcare Improvement, shares his insights on why health care is difficult to fix and his optimism that systems can be changed to reduce, and even eliminate, medical error.
Breast Cancer Services in Trafford and North Manchester. An Investigation Into The Circumstances Surrounding A Serious Clinical Incident In Symptomatic Breast Services – The Baker Report.
Baker M. Manchester, England: NHS North West; February 2007.
This report shares findings from an investigation into individual and system failures that contributed to a radiologist misreading mammograms for a 2-year period.
Victoria Times Colonist. March 26, 2007.
This article reports on findings from an investigation into hospital-acquired infections in British Columbia.
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.
Landro L. Wall Street Journal. April 4, 2007:D5.
This article reports on initiatives to standardize the color designations of color-coded wristbands to avoid confusion and reduce the risk of error.
US News & World Report. July 3, 2008.
This article discusses the findings of a recent study that reported deficiencies in barcode systems requiring numerous overrides and "workarounds" by nurses.
Berens MJ, Armstrong K. Seattle Times. November 16-18, 2008.
This three-part journalistic investigation highlights efforts in Washington State to track and minimize the spread of methicillin-resistant Staphylococcus aureus (MRSA) and to address organizational resistance to changes needed to mitigate the problem.
Rein L. Washington Post. July 21, 2009:E1.
This news article reports on Washington, DC–area initiatives to track preventable patient injury and discusses strategies to hold hospitals accountable to reduce the number of avoidable incidents.
Bogdanich W. New York Times. January 24, 2010:A1.
First in a series on medical radiation, this news feature and accompanying video investigate patient deaths and injuries following mistakes related to radiation treatment. The journalists discuss the number of radiation therapy errors in New York and reveal that state law does not require public reporting of such mistakes.
Zarembo A. Los Angeles Times. April 6, 2010.
This newspaper article reports on device failures in the context of organizational and individual accountability for unreliable equipment, aborted surgery, and treatment delay.
Austin, TX: Texas Medical Institute for Technology and the Quaid Foundation; 2010.
This documentary reports on families affected by medical errors; it includes the story of a high-profile heparin overdose and how it transformed the family of actor Dennis Quaid into advocates for patient safety.
Harris G. New York Times. August 21, 2010:A1.
This article describes documented look-alike issues with medical equipment that have yet to be addressed by federal regulation.
Harasim P. Las Vegas Review-Journal. November 21, 2010;News:1B.
This article discusses how the organizational system of one hospital delayed an investigation into catheter line malfunctions.
Landro L. Wall Street Journal. May 10, 2011:D3.
This newspaper article reports on efforts to reduce errors in emergency medicine, including improving physician–nurse communication, adopting timeouts before discharge, and using trigger systems.
Graham J, Dizikes C. Chicago Tribune. June 27, 2011.
This newspaper article reports on an order entry error that resulted in a 60-fold overdose and raised concerns about the safety of electronic medication data systems.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; December 6, 2012.
Chen PW. New York Times. February 14, 2013.
This newspaper article reports on a recent commentary discussing how hierarchy among physicians can influence the care they deliver.
Brown T. New York Times. March 17, 2013:SR5.
Chen PW. New York Times. April 18, 2013.
Tools/Toolkit > Multi-use Website
Rockville, MD: Agency for Healthcare Research and Quality; June 2013.
Studies have shown that a surprisingly large proportion of hospitalized patients are not aware of their diagnoses or treatment plan and that their preferences are often not taken into account in advanced care planning. This failure to provide patient-centered care indicates a need for increased patient engagement in safety and quality efforts. This toolkit published by the Agency for Healthcare Research and Quality is designed to help hospitals develop partnerships with patients around improving safety. Developed with input from clinicians and patients, the guide emphasizes four strategies—working with patients as advisors, improving bedside communication, integrating patients and families into shift changes, and using patient input to improve the discharge process. An AHRQ WebM&M perspective by Dr. Saul Weingart discusses the practical challenges of engaging patients in improvement efforts.
Gunderman R, Lynch J, Harrell H. The Atlantic. September 3, 2013.
This magazine article reports on the unique tension between efficiency mandates and patient-centered care through the example of a cancer patient whose suicidal thoughts might have been missed if not for a curious medical student delving further into the patient's medication concerns during a routine follow-up appointment.
Towne S. WPRI. November 2, 2011.
This article reports on a software malfunction that caused prescription errors affecting patients discharged from several Rhode Island hospitals.
Snyderman N. NBC News. February 22, 2012.
This news video reports how inadequate sterilization of surgical instruments can affect patient safety.
Landro L. Wall Street Journal. June 5, 2012;D1.
This newspaper article describes how one hospital reduced hospital-acquired infection rates.
Kolata G. New York Times. August 22, 2012.
Despite strict infection controls placed around a patient carrying a deadly antibiotic-resistant bacteria, 17 other patients also became infected and 6 died. This newspaper article details the approach used to track the chain of transmission.
Makary M. New York, NY: Bloomsbury Press; 2012. ISBN: 9781608198368.
Audiovisual > Image/Poster
Mableton, GA: Safe Care Campaign.
This Web site provides patient safety resources, including posters and videos with information on hand hygiene, infection prevention, and medication errors.
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.
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.
Catalanello R. The Times-Picayune. April 15, 2014.
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.
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.