Narrow Results Clear All
- Patient Safety Primers 1
- WebM&M Cases 2
- Perspectives on Safety 2
- Study 19
- Book/Report 12
- Legislation/Regulation 1
- Newspaper/Magazine Article 5
- Special or Theme Issue 2
- Toolkit 3
- Web Resource 7
- Meeting/Conference 1
- Communication Improvement
- Education and Training 19
- Error Reporting and Analysis 8
- Human Factors Engineering 7
- Legal and Policy Approaches 6
- Quality Improvement Strategies 11
- Research Directions 2
- Technologic Approaches 7
- Device-related Complications 1
- Diagnostic Errors 1
- Discontinuities, Gaps, and Hand-Off Problems 6
- Identification Errors 2
- Medical Complications 2
- Medication Safety 23
- Nonsurgical Procedural Complications 1
- Psychological and Social Complications 2
- Surgical Complications 1
- Health Care Executives and Administrators 32
- Health Care Providers 38
Non-Health Care Professionals
- Educators 30
- Patients 13
- Australia and New Zealand 1
- Europe 2
- North America 41
Search results for ""
Cases & Commentaries
- Web M&M
Dean Schillinger, MD; March 2004
A misunderstanding of instructions on how to administer medication leads to an infant choking on a syringe cap.
Cases & Commentaries
- Spotlight Case
- Web M&M
Ted Eytan, MD, MS, MPH; October 2008
An elderly, non–English-speaking man with diabetes was admitted to the hospital twice in 8 days due to hypoglycemia. At discharge, the patient was instructed not to take any antidiabetic medications. In between hospitalizations, he saw his primary care physician, who restarted an antidiabetic medication.
Perspectives on Safety > Perspective
with commentary by Michael S. Wolf, PhD, MPH; Stacy Cooper Bailey, MPH, Health Literacy and Safety, February-March 2009
Clear health communication is increasingly recognized as essential for promoting patient safety. Yet according to a recent Joint Commission report, What Did the Doctor Say? Improving Health Literacy to Protect Patient Safety, communication problems among health care providers, patients, and families are common and a leading root cause of adverse outcomes. Addressing health literacy—the capacity of individuals to obtain, process, and understand basic health information and services needed to make appropriate health decisions—has become a primary objective for many health systems in order to protect patients from harm.
Perspectives on Safety > Interview
Health Literacy and Safety, February-March 2009
Dean Schillinger, MD, is a Professor of Medicine at University of California, San Francisco, Director of the UCSF Center for Vulnerable Populations, and Chief of the California Diabetes Prevention and Control Program. His role as a practicing clinician at a safety net hospital (San Francisco General Hospital) has put him in a unique position to pursue influential and relevant research related to health literacy and improving care for vulnerable populations.
Patient Safety Primers
Anyone can find it challenging to understand medical terms, and millions of Americans have trouble understanding and acting upon health information. The mismatch between individuals' health literacy skills and the complexity of health information and health care tasks involved in managing health has implications on patient safety.
Tools/Toolkit > Toolkit
This four-chapter report defines "health literacy" and provides strategies for states to address existing educational gaps. It outlines the existing activities of interested stakeholders and summarizes the findings of a survey conducted by the Council on State governments. The report ultimately offers supportive tools for state policy makers to clarify relevant issues in their own states.
Tools/Toolkit > Multi-use Website
Johns Hopkins University, Department of Anesthesiology & Critical Care Medicine.
This Web site provides information on the multidisciplinary safety team at Johns Hopkins University, including research projects, presentations, and useful tools for patients, families, and practitioners.
Committee on Identifying and Preventing Medication Errors, Aspden P, Wolcott J, Bootman JL, Cronenwett LR, eds. Washington, DC: The National Academies Press; 2007.
A major report by the Institute of Medicine (IOM) on medication errors suggests that, despite all the progress in patient safety since To Err is Human, medication errors remain extremely common, and the health care system can do much more to prevent them. Among the startling statistics from this report: more than 1.5 million Americans are injured every year in American hospitals, and the average hospitalized patient experiences at least one medication error each day. The report emphasizes actions that health care systems, providers, funders, and regulators can take to improve medication safety. These actions include having all US prescriptions written and dispensed electronically by 2010, more widespread use of medication reconciliation, and additional research on drug errors and how to prevent them. Importantly, the report also emphasizes actions that patients can take to prevent medication errors, such as maintaining active medication lists and bringing their medications to appointments. Support for the IOM report came from the Centers for Medicare & Medicaid Services.
The Health Literacy of America's Adults: Results from the 2003 National Assessment of Adult Literacy.
Kutner M, Greenberg E, Jin Y, Paulsen C. US Department of Education. Washington, DC: National Center for Education Statistics; September 2006. Report No: NCES 2006-483.
This report provides an assessment of health literacy data analyzed for different demographic characteristics.
Kaiser Family Foundation, Agency for Healthcare Research and Quality; September 2006.
This survey follows up on a prior study from 2004, asking patients about their perceptions of health care quality and medical errors. The study found minimal change since 2004 in overall impression of US health care quality, with approximately half of respondents stating they are "dissatisfied" with quality, particularly with coordination of care. More patients are aware of information comparing the quality of hospitals, health care plans, or providers, but only a small minority report using this information to make health care decisions. A large proportion of patients reported taking recommended actions to improve safety, such as bringing a list of their medications to appointments or following up on test or procedure results. As found in other studies, survey respondents overwhelmingly expressed support for full, mandatory disclosure of all preventable errors, and two-thirds felt errors should be publicly reported.
Kapadia R. Smart Money. October 2006;15:112-114.
This article provides tips for consumers to help keep their hospital care as safe and hassle-free as possible.
Foubister V. Quality Matters. November/December 2006.
This article describes the concept of health literacy and efforts to measure and improve health literacy in the United States.
St. Paul, MN: Minnesota Department of Health; January 2009.
This report provides background on the Minnesota Never Events reporting initiative, tips for patients on how to receive the safest care possible, and a table of events reported by all hospitals in the state.
Oakbrook Terrace, IL: The Joint Commission; 2007.
Low health literacy is a recognized patient safety problem. Prior research has demonstrated that patients with impaired health literacy have difficulty comprehending prescription instructions and warnings. This Joint Commission report, developed by an expert panel, contains specific recommendations for improving provider–patient communication, in order to ameliorate the problem of low health literacy as much as possible. The report recommends that organizations establish communication as a patient safety priority and calls for financial support for patient-centered care initiatives.
Smerd J. Workforce Management. June 11, 2007;1, 16-19.
This article discusses the financial impact on employers when an employee is affected by medical error.
Special or Theme Issue
Glover ED, ed. Am J Health Behav. 2007;31(suppl):s1-s133.
This issue supplement includes articles and commentaries that explore avenues for improvement in health literacy research.
Barrett SE, Puryear JS, Westpheling K. New York, NY: The Commonwealth Fund; January 2008.
This report describes tactics for clear communication with patients in primary care practices and provides recommendations to improve health literacy.
Journal Article > Study
Randomized controlled trial of a pictogram-based intervention to reduce liquid medication dosing errors and improve adherence among caregivers of young children.
Yin HS, Dreyer BP, van Schaick L, et al. Arch Pediatr Adolesc Med. 2008;162:814-822.
Journal Article > Study
Franks AS, Ray SM, Wallace LS, Keenum AJ, Weiss BD. Ann Pharmacother. 2008;43:51-56.
Prior research has demonstrated that health literacy is directly linked to comprehension of medication instructions. This study found that sample medications lacked instructions that could be understood by patients with average or low health literacy, which could predispose to adverse drug events.
Journal Article > Study
Using consumer-based kiosk technology to improve and standardize medication reconciliation in a specialty care setting.
Lesselroth B, Adams S, Felder R, et al. Jt Comm J Qual Patient Saf. 2009;35:264-271.
This study used an innovative approach to involving patients in safety efforts by using an interactive kiosk paired with the medication list from the electronic health record. When patients presented for a clinic visit, the kiosk presented their presumed medication list along with pill pictures, and patients had to indicate if they were taking the medication. This method successfully identified medication discrepancies and reduced the time spent by staff in reviewing medications. Ensuring medication reconciliation in ambulatory care has been particularly problematic for patients with low health literacy. This novel strategy may represent an effective, patient-centered approach to this problem.