Narrow Results Clear All
- Communication Improvement
- Culture of Safety 4
- Education and Training 7
- Error Reporting and Analysis 7
- Human Factors Engineering 5
- Legal and Policy Approaches 4
- Logistical Approaches 1
- Quality Improvement Strategies 8
- Specialization of Care 1
- Teamwork 5
- Clinical Information Systems 2
- Device-related Complications 1
- Diagnostic Errors 1
- Discontinuities, Gaps, and Hand-Off Problems 3
- Identification Errors 16
- Medical Complications 1
- Medication Safety 6
- Nonsurgical Procedural Complications 1
- Surgical Complications 11
Search results for "Newspaper/Magazine Article"
- Newspaper/Magazine Article
- Read Back Protocols
ISMP Medication Safety Alert! Acute Care Edition. May 18, 2017;22:1-4.
Verbal orders are known to increase risk of error in care. This newsletter article summarizes survey results that sought to characterize current verbal order behaviors. Notably, practices to improve the reliability of verbal orders such as read backs were not optimally integrated in medication processes. The article includes recommendations for organizations, individuals, and teams to improve the safety of verbal orders.
Clarke JR. PA-PSRS Patient Saf Advis. 2015;12:19-27.
Wrong-site surgeries are considered never events by the National Quality Forum and sentinel events by The Joint Commission. Drawing from data submitted to the Pennsylvania Patient Safety Authority, this article analyzes 83 wrong-site extremity procedures in orthopedic surgery reported over 9 years and recommends site marking and time outs as strategies to prevent these incidents.
Huff C. Trustee Magazine. October 2011.
This article reports on patient safety improvement work in the Veterans Affairs hospital system and describes the implementation of a team training program.
Boodman SG. Washington Post. June 21, 2011:E1.
PA-PSRS Patient Saf Advis. June 2011;8:63-69.
Exploring causes of wrong-site, wrong patient, and wrong procedure errors in radiology, this piece suggests strategies to reduce the incidence of such events.
Rojas-Burke J. The Oregonian. May 25, 2011.
Landro L. Wall Street Journal. May 10, 2011:D3.
This newspaper article reports on efforts to reduce errors in emergency medicine, including improving physician–nurse communication, adopting timeouts before discharge, and using trigger systems.
Oops, sorry, wrong patient! A patient verification process is needed everywhere, not just at the bedside.
ISMP Medication Safety Alert! Acute Care Edition. March 10, 2011;16:1-4.
This piece identifies situations in which patient verification errors occur and provides strategies to address them.
ISMP Medication Safety Alert! Acute Care Edition. February 9, 2011;16:1-3.
This piece discusses medication errors during emergency resuscitations and outlines risk-reduction strategies.
O'Reilly KB. American Medical News; Nov. 1, 2010.
This article reports on recent study findings indicating that the Universal Protocol has not stopped wrong-patient, wrong-site procedures.
ISMP Medication Safety Alert! Acute Care Edition. July 1, 2010;15:1-2.
This piece reports on examples of confusion between adult and pediatric immunizations and states that the similar abbreviations are a main cause of the problem.
Stein L. St. Petersburg Times. June 21, 2010.
Reporting on wrong-site surgeries in Florida hospitals, this newspaper article describes how timeouts have changed the nature and frequency of surgical errors.
O'Reilly KB. American Medical News. June 14, 2010.
This news piece discusses how the health care industry can apply aviation safety methodologies to guide improvement.
Case study: sustaining a culture of safety in the U.S. Department of Veterans Affairs Health Care System.
Chase D, McCarthy D. Quality Matters. April/May 2010.
Gardner E. Mod Healthc. May 18, 2009;39:28-31.
This article describes how one health system markedly improved its quality and safety by applying a safety technique used in the nuclear power industry.
Lerner M. Minneapolis Star Tribune. January 25, 2009:B1.
This newspaper article highlights a simple innovation one hospital is using to trigger a time out in the operating room.
Freyer FJ. Providence Journal. September 20, 2008.
This story reports on an incident involving wrong-side surgery and describes how the hospital responded to the event.
Smith S. Boston Globe. July 30, 2008;Metro section:1A.
This article reports on the incidence of wrong site surgeries in Massachusetts and describes complex factors that may contribute to such errors occurring in spinal surgery.
PA-PSRS Patient Saf Advis. December 2007;4:109, 112-123.
This article summarizes a state-level analysis that used site visits along with near miss and error reports to evaluate wrong-site surgeries.
PA-PSRS Patient Saf Advis. June 2007;4:29, 32-45.
This article discusses reports of wrong-site surgery submitted to the PA-PSRS, compares them with results of other studies, and provides suggestions to reduce this type of error.