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- Communication Improvement 14
- Culture of Safety 3
- Education and Training 4
- Error Reporting and Analysis 9
- Human Factors Engineering 7
- Legal and Policy Approaches 8
- Logistical Approaches 2
- Policies and Operations 1
- Quality Improvement Strategies 8
- Specialization of Care 1
- Teamwork 1
- Technologic Approaches 4
- Device-related Complications 1
- Diagnostic Errors 3
- Discontinuities, Gaps, and Hand-Off Problems 6
- Failure to rescue 1
- Identification Errors 1
- Medical Complications 1
- Medication Safety 7
- Nonsurgical Procedural Complications 1
- Overtreatment 1
- Psychological and Social Complications 7
- Surgical Complications 1
- Transfusion Complications 1
- Surgery 1
- Nursing 2
- Pharmacy 1
- Family Members and Caregivers 6
- Health Care Executives and Administrators
Health Care Providers
- Nurses 4
Non-Health Care Professionals
- Media 2
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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.
Weber T, Ornstein C. Los Angeles Times. April 12, 2005.
This article reports on a death that occurred at the Martin Luther King Jr./Drew Medical Center after a patient's deteriorating vitals signs went unnoticed.
Journal Article > Commentary
Kopec D, Levy K, Kabir M, Reinharth D, Shagas G. Stud Health Technol Inform. 2005;114:110-116.
The authors describe a taxonomy of medical error based on the Institue of Medicine's classification in To Err is Human. They submit that this classification model will facilitate pattern recognition and aid in understanding the nature of medical errors.
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.
Gray R. Scotland on Sunday. January 8, 2006.
This story discusses the impact of a computer glitch in a system used by more than 80% of general practitioners in Scotland. In addition to physician notes being inadvertently attached to the wrong patient's medical record, reports suggest that some patients actually received incorrect prescriptions due to printing errors caused by the system.
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.
Hydrocodone bitartrate and acetaminophen tablets, phenobarbital tablets by Qualitest: recall—incorrect package labeling.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; February 7, 2011.
This announcement reports the recall of two products that may have been mislabeled.
Brown T. New York Times. March 17, 2013:SR5.
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.
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.
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.
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.
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.
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.
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.
Mohr H, Weiss M. Associated Press. November 27, 2018.
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.