Narrow Results Clear All
- Communication Improvement 10
- Culture of Safety 3
- Education and Training 2
- Error Reporting and Analysis 3
- Human Factors Engineering 3
- Logistical Approaches 3
- Quality Improvement Strategies 6
- Specialization of Care
- Clinical Information Systems 2
- Alert fatigue 1
- Discontinuities, Gaps, and Hand-Off Problems 4
- Failure to rescue 1
- Medical Complications 5
- Medication Safety 6
- Nonsurgical Procedural Complications 1
- Psychological and Social Complications 1
- Surgical Complications 2
- Family Members and Caregivers 2
- Health Care Executives and Administrators 12
- Health Care Providers 15
- Non-Health Care Professionals 9
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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.
Washington, DC: Leapfrog Group.
This website offers resources related to the Leapfrog Hospital Survey investigating hospitals' progress in implementing specific patient safety practices. Updates to the survey include increased time allotted to complete computerized provider order entry evaluation, staffing of critical care physicians on intensive care units, and use of tools to measure safety culture. Reports discussing the results are segmented into specific areas of focus such as health care-associated infections and medication errors.
Gawande A. The New Yorker. December 6, 2004;82-91.
A sensitive portrayal of the challenges in defining quality and implementing change even when practitioners are committed to high-quality care.
Saving lives: hospitals have signed on to a six-part plan to avoid a multitude of unnecessary deaths.
Comarow A. US News & World Report. July 18, 2005;139:74,76,79.
This article, accompanying the widely read ranking of "America's Best Hospitals," describes the Institute for Healthcare Improvement's 100,000 Lives Campaign. Focusing on the six practices promoted by the campaign, it reviews the progress to date, with a particular focus on two participating hospitals' (Hackensack University Medical Center in New Jersey and McLeod Regional Medical Center in South Carolina) experiences in implementing the practices.
Srikameswaran A. Pittsburgh Post-Gazette. July 17, 2005;Health section.
This article describes medical emergency teams and how they are being utilized in several hospitals.
Kowalczyk L. The Boston Globe. November 27, 2005:A1.
This article reports on the implementation of rapid response teams in Boston hospitals and the potential for reducing patient mortality.
Hua V. San Francisco Chronicle. February 17, 2006:B6.
This article reports on a study conducted by the Discrimination Research Center that found non-English speakers were not connected to a staff member who spoke the language in about half of calls to the emergency department.
ISMP Medication Safety Alert! Acute Care Edition. June 1, 2006:1-2.
This article discusses one hospital's initiative to empower patients and their families to call for a rapid response team if they feel it is necessary.
P-I Staff and News Services. Seattle Post-Intelligencer. June 15, 2006:A1.
This article article reports on the results of the the 100,000 Lives Campaign.
Web Resource > Multi-use Website
Development of The Patient Safety Group was motivated by the death of a young girl named Josie King. The King family responded to their personal experience from medical errors by making a commitment to improve and advance safety and quality in health care. They created a program entitled eCUSP (electronic comprehensive unit-based safety program) as a mechanism for providers to manage and organize their patient safety efforts.
Journal Article > Study
Coleman EA, Parry C, Chalmers S, Min SJ. Arch Intern Med. 2006;166:1822-1828.
Prior studies have documented the safety problems that befall patients with complex illnesses at the time of transition from one setting of care to another. In this trial conducted in an integrated delivery system, patients were randomized to receive usual care or the care transitions intervention at the time of hospital discharge. Intervention patients received a personal health record and a "transition coach," who assisted with continuity of care across settings, arranged home visits after discharge, and helped train patients and caregivers in self-care methods. The foci of the intervention were on ensuring accurate medication usage and appropriate follow-up care. The intervention successfully reduced the likelihood of hospital readmission for 3 months after discharge and appeared to be cost effective.
Pittsburgh, PA: UPMC Shadyside Hospital; 2012.
This brochure informs patients and their families about the Condition H helpline at University of Pittsburgh Medical Center (UPMC) Shadyside hospital, which can be used to call a rapid response team to immediately address concerns in a patient's condition. The helpline was developed in memory of Josie King.
Berwick DM, Leape LL. Newsweek. October 16, 2006:70-71.
As part of the "Health for Life" series, Drs. Berwick and Leape discuss the notion of completely eliminating medical errors and share stories about several hospitals' efforts to raise safety standards.
Newsweek. October 16, 2006:44-68, 72.
This "Health for Life" series features 10 case studies about patient safety and quality improvement efforts as well as several short articles on safety-related topics such as disclosure and computerizing medical care.
Landro L. Wall Street Journal. July 11, 2007:D1.
This article reports on hospitals that are creating dedicated teams of experts who have the skills to perform risky medical procedures.
Wang SS. Washington Post. September 4, 2007;Health section:1.
This article discusses the advent of rapid response teams and describes how several hospitals have empowered patients or their families to initiate them.
Landro L. Wall Street Journal. May 28, 2008:D1.
This article reports how hospitals are aiming to boost the safety of care delivered on nights and weekends by employing "nocturnists" (a hospitalist subspecialty)—physicians who work only the night shift.
Landro L. Wall Street Journal. September 1, 2009:D2.
This column explains that some hospitals now afford patients and families the right to summon an immediate clinical response to a patient's worsening condition.
Dao J, Carey B, Frosch D. New York Times. February 13, 2011;A1.
This newspaper article reports on the risks of polypharmacy in veterans and discusses the need to improve monitoring to prevent fatal medication errors.
Kowalczyk L. Boston Globe. February 13–14, 2011.