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- Communication Improvement 2
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Education and Training
- Students 2
- Error Reporting and Analysis 2
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- Legal and Policy Approaches 1
- Quality Improvement Strategies 2
- Teamwork 1
- Technologic Approaches
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Cases & Commentaries
- Web M&M
Mary A. Blegen, PhD, RN; Ginette A. Pepper, PhD, RN; May 2006
A nursing student administers the wrong 'cup' of medications to an elderly man. A different student discovered the error when she reviewed the medicines in her patient's cup and noticed they were the wrong ones.
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.
Journal Article > Review
Woodward HI, Mytton OT, Lemer C, et al. Annu Rev Public Health. 2010;31:479-497.
This narrative review provides a broad perspective on the current understanding of medical errors and the evidence behind commonly adopted prevention strategies. The authors then highlight a series of recommendations to improve patient safety.
Legislation/Regulation > Sentinel Event Alerts
Sentinel Event Alert. January 26, 2010;(44):1-4.
The Joint Commission issues Sentinel Event Alerts to highlight areas of high risk and to promote the rapid adoption of risk reduction strategies. Adherence to these recommendations is then assessed as part of Joint Commission accreditation surveys at health care organizations nationwide. This recently retired alert targets prevention of maternal death and highlights the need to manage blood pressure, pay attention to vital signs following cesarean delivery, and hemorrhage. The alert also provides recommendations around educational strategies, identifying specific clinical triggers for action, and conducting adequate risk assessments. As of September 2016, current guidance will being distributed by a new initiative.
Special or Theme Issue
Singh H, ed. BMJ Qual Saf. 2013;22(suppl 2):ii1-ii72.
Journal Article > Study
O'Sullivan ED, Schofield SJ. BMC Med Educ. 2019;19:12.
This simulation study randomized physicians to identify the correct diagnosis in a standardized case, either with the aid of a debiasing exercise or without any prompting. Even though the participants believed that the debiasing tool was effective, it did not improve diagnostic accuracy. These results underscore the challenge of enhancing diagnostic cognition.