Narrow Results Clear All
- Communication between Providers 19
- Culture of Safety 9
- Education and Training 8
Error Reporting and Analysis
- Error Reporting 12
- Human Factors Engineering 28
- Legal and Policy Approaches 9
- Logistical Approaches 7
- Quality Improvement Strategies 42
- Specialization of Care 7
- Teamwork 6
- Clinical Information Systems 13
- Device-related Complications 6
- Diagnostic Errors 7
- Discontinuities, Gaps, and Hand-Off Problems 11
- Fatigue and Sleep Deprivation 1
- Identification Errors 5
- Interruptions and distractions 3
- Medical Complications 9
- Medication Errors/Preventable Adverse Drug Events 41
- Nonsurgical Procedural Complications 2
- Psychological and Social Complications 3
- Surgical Complications 16
- Internal Medicine 49
- Nursing 8
- Pharmacy 17
- Family Members and Caregivers 1
- Health Care Executives and Administrators
Health Care Providers
- Nurses 18
- Physicians 23
- Non-Health Care Professionals 35
- Patients 7
- Europe 7
- Canada 1
Search results for "Newspaper/Magazine Article"
ISMP Medication Safety Alert! Acute Care Edition. June 6, 2019;24.
ISMP National Vaccine Errors Reporting Program: one in three vaccine errors associated with age-related factors.
ISMP Medication Safety Alert! Acute Care Edition. July 28, 2016;21:1-6.
Vaccine errors can hinder immunization efforts in the United States. Summarizing nearly 4 years of data submitted to the ISMP Vaccine Errors Reporting Program, this newsletter article highlights age-related factors that surfaced in the analysis and recommends strategies for improvement such as patient education and age verification.
Gardner LA. PA-PSRS Patient Saf Advis. June 2016;13:58-65.
Insufficient health literacy is a known patient safety hazard. This article reviews incidents submitted to a state reporting initiative where insufficient patient understanding may have played a role in delayed or missed care and describes a program to encourage adoption of teach-back and other strategies to help patients better comprehend their health care instructions. A past PSNet perspective discussed the role of health literacy in patient safety.
Miller N. The Pathologist. June 2016(20):18-29; July 2016(21):18-33.
In light of the growing focus on diagnostic errors, this magazine series reports on unique challenges that pathologists face when they discover potential errors. The first article in the series discusses how pathologists may experience barriers to disclosure including feeling shame in disclosing their own error, discomfort with raising concerns about a colleague who has misdiagnosed a patient, and lack of direct relationships with patients. The second article expands the discussion to focus on how industry support of open transparency can enable pathologists to participate in reporting and disclosure activities.
ED Manag. June 2016;28:S1-S4.
Butler M. J AHIMA. March 2015;86:18-23.
Although health information technology presents opportunities to improve patient safety, it can also introduce risks. This commentary discusses how insufficient interoperability, data integrity, training, and protection against copy-and-paste errors can hinder optimal use of electronic health record systems.
ISMP Medication Safety Alert! Acute Care Edition. November 20, 2014;19:1-3.
Reviewing an incident involving a patient who reported an error with home infusion of chemotherapy which was later determined to be a false alarm, this newsletter article outlines actions that could have been taken to prevent wasted resources and anxiety for the patient and health care providers.
A crack in our best armor: "wrong patient" injections from insulin pens alarmingly frequent even with barcode scanning.
ISMP Medication Safety Alert! Acute Care Edition. October 23, 2014;19:1-5.
Improper insulin pen use is a persistent problem. This newsletter article reveals the lessons learned from one hospital that implemented best practices including robust education, bar-code scanning, bedside electronic medication administration records, and alerts to prevent incorrect administration but continued to experience errors related to insulin pen use.
Connor M, Wayman KI, Garcia C, Fischer PR; Consortium for Maximizing Family-Centered Care. Patient Saf Qual Healthc. September/October 2014;11:36,38-40,42.
Patients are increasingly encouraged to take an active role in their own safety during hospital care. Describing a near miss of a medication error, this magazine article examines elements of effective disclosure and how engaging patients and their families can contribute to error investigations and safety improvement.
ISMP Medication Safety Alert! Acute Care Edition. October 9, 2014;19:1-5.
Changes in practice require time and monitoring to achieve lasting improvements. This newsletter article highlights issues that continue to hinder medication safety, including inconsistent availability of patient counseling, misuse of prefilled syringes, and disrespectful behavior toward both peers and patients.
Dubeck D. PA-PSRS Patient Saf Advis. September 2014;11:93-101.
Research has documented a substantial learning curve for surgeons as they develop skills to use robotic technologies. Drawing from data submitted to the Pennsylvania Patient Safety Authority, this article analyzes the 722 safety events involving robotic-assisted surgery reported since 2005—approximately 75% of these incidents did not result in harm but 10 patient deaths were recorded—and discusses the challenges introduced as robotic-assisted surgery becomes accepted as standard surgical practice.
Wild D. Pharmacy Practice News. September 8, 2014.
Highlighting how hospital compliance rates with Joint Commission medication–related standards have remained mostly unchanged from 2012 to 2013, this article provides information about the most problematic areas identified—medication storage, drug orders, pharmacist review, labeling, and medication reconciliation—along with ways to address them.
Carr S. Patient Saf Qual Healthc. July/August 2014;11:30-35.
This magazine article summarizes experts' projections for the patient safety movement in the next 5 years. Areas discussed include expanding the focus of safety to investigate public health concerns, enhancing patient engagement, improving interoperability of electronic health records, and driving culture change.
Clark C. HealthLeaders Media. July 24, 2014.
The Hospital Compare Web site has begun to publicly report which hospitals are using checklists, and the results are concerning. Investigating reasons behind these findings, this news piece offers insights from physicians into why checklists have not been universally implemented and highlights the importance of developing a culture of safety to drive improvement efforts.
ISMP Medication Safety Alert! Acute Care Edition. July 17, 2014;19:1-4.
To illustrate hazards associated with dispensing more than one dose of certain medications, this newsletter article describes an incident involving an accidental overdose of self-administered oral chemotherapy which resulted in a patient's death. Recommendations to reduce the potential for errors include ensuring labels conform to FDA labeling practices, dispensing only single doses, and providing medication counseling and written instructions for patients.
Survey suggests possible downward trend in identifying key drugs/drug classes as high-alert medications.
ISMP Medication Safety Alert! Acute Care Edition. July 3, 2014;19:1-3,5-6.
Fibuch E, Ahmed A. Physician Exec. Jul-Aug 2014;40:28-32.
Failure mode and effects analysis (FMEA) has been recommended as a method to detect safety hazards and proactively address system flaws. This article reviews the initial purpose of FMEA, provides a breakdown of the process, describes a scoring tool applying Six Sigma designations to determine probability of failure, and discusses how FMEA is used in health care settings.
Multifaceted initiative to reduce "alarm fatigue" on cardiac unit reduces alarms and increases nurse and patient satisfaction.
Agency for Healthcare Research and Quality. Health Care Innovations Exchange. June 18, 2014.
Clinical alarms have been described as a serious patient safety issue. This article relates how one hospital implemented a series of actions reduce nuisance alarms in a cardiac unit and reports a substantial decrease in audible alerts with no subsequent adverse effects. Interventions included expanding limits for triggering heart rate alarms and collaboration between two nurses to design customized alarm parameters for individual patients.
24-Hour inpatient pulse oximetry monitoring reduces rescue events and intensive care unit transfers.
Agency for Healthcare Research and Quality. Health Care Innovations Exchange. June 18, 2014.
Effective monitoring can enable early detection of deteriorating patients while reducing nuisance alarms. Relating how one hospital implemented round-the-clock monitoring and adjusted alarm thresholds, this article reports results of the program such as fewer patient transfers to the intensive care unit and no subsequent adverse events.
Feil M. PA-PSRS Patient Saf Advis. June 2014;11:45-52.
Operating rooms are complex environments with particular risks regarding interruptions and distractions. This article draws from data reported to the Patient Safety Authority to explore how distractions affect surgeons and other team members. The author reviews strategies to limit distractions, including applying sterile cockpit principles, performing preoperative briefings, and utilizing checklists.