Narrow Results Clear All
- Communication between Providers 24
- Culture of Safety 13
Education and Training
- Students 4
Error Reporting and Analysis
- Error Reporting 44
Human Factors Engineering
- Checklists 13
- Legal and Policy Approaches 65
- Logistical Approaches 11
- Policies and Operations 5
- Quality Improvement Strategies 42
- Specialization of Care 7
- Teamwork 7
- Clinical Information Systems 19
- Transparency and Accountability 5
- Alert fatigue 3
- Device-related Complications 10
- Diagnostic Errors 28
- Discontinuities, Gaps, and Hand-Off Problems 14
- Drug shortages 4
- Failure to rescue 1
- Fatigue and Sleep Deprivation 3
- Identification Errors 7
- Interruptions and distractions 1
- Delirium 1
- Medication Errors/Preventable Adverse Drug Events 53
- Nonsurgical Procedural Complications 2
- Overtreatment 3
- Psychological and Social Complications 25
- Second victims 4
- Surgical Complications 27
- Transfusion Complications 1
- Ambulatory Care 38
- General Hospitals 40
- Long-Term Care 6
- Outpatient Surgery 5
- Psychiatric Facilities 1
- Allied Health Services 2
- Dentistry 1
- Geriatrics 11
- Internal Medicine 62
- Nursing 13
- Pharmacy 30
- Family Members and Caregivers 9
- Health Care Executives and Administrators 109
Health Care Providers
- Nurses 19
- Pharmacists 15
- Physicians 37
Non-Health Care Professionals
- Media 2
- Patients 132
- Europe 7
- Canada 3
United States of America
United States Federal Government
- Department of Health and Human Services (HHS) 10
- United States Federal Government 12
Search results for "Newspaper/Magazine Article"
- Newspaper/Magazine Article
- Epidemiology of Errors and Adverse Events
Appleby J, Lucas E. Kaiser Health News. June 21, 2019.
ISMP Medication Safety Alert! Acute Care Edition. June 6, 2019;24.
Butcher L. Managed Care. June 2019;28:37-39.
Inconsistent patient name entry practices in electronic health records can contribute to wrong-patient errors. This magazine article reports on the complex nature of addressing patient-matching discrepancies as an economic, privacy, and technical problem. Improvement strategies include the development and adoption of a national identification program and biometric technology. A WebM&M commentary discussed problems associated with name similarities in the electronic patient record.
Gabler E. New York Times. May 31, 2019.
Pediatric cardiac surgery is highly technical and risky. This newspaper article reports on a poorly performing pediatric cardiac surgery program, concerns raised by staff, and insufficient response from organizational leadership. Lack of data transparency, insufficient resources, and limited program capabilities to support a complex program contributed to poor outcomes for pediatric patients.
Hilton K, Anderson A. Harv Bus Rev. May 20, 2019.
This commentary describes how one health system worked to combat resistance to change associated with implementation of a checklist initiative. The success of the program was built on empowering team members to drive the process, clinician motivation to provide safe care, and engaging leadership. A PSNet interview with Lucian Leape discussed surgical safety checklists.
Ross C. STAT. May 13, 2019.
Nuisance alarms, interruptions, and insufficient staff availability can hinder effective monitoring and response to acute patient deterioration. This news article reports on how hospital logistics centers are working toward utilizing artificial intelligence to improve clinician response to alarms by proactively identifying hospitalized patients at the highest risk for heart failure to trigger emergency response teams when their condition rapidly declines.
CDC Vital Signs. May 7, 2019.
Maternal morbidity and mortality is a worldwide patient safety problem. This analysis describes the prevalence of pregnancy-related death and areas of concern during pregnancy, at delivery, and up to a year postpartum. It reports that 60% of these deaths are preventable and provides suggestions for families, clinicians, and systems to reduce risks.
Frakt A. New York Times. April 29, 2019.
Health care providers are a known source of potentially harmful bacteria due to their perpetual interaction with germs during practice. This newspaper article reports on how clinician attire, stethoscopes, and technology can be contaminated with bacteria. Hand sanitizer placement, sleeve length, and laundering behaviors can reduce transmission of pathogens.
ISMP Medication Safety Alert! Acute Care Edition. April 25, 2019.
Newborns assigned temporary names are at increased risk for patient misidentification and wrong-patient errors. This newsletter article reports on the role of electronic health records in newborn misidentification and the unintended consequences associated with a Joint Commission set of recommendations to reduce risk.
Cheney C. HealthLeaders Media. April 17, 2019.
This news article describes how a 19-hospital health system successfully applied high reliability principles to emphasize a zero-tolerance focus on patient harm. The coordinated effort across the system achieved a drop in readmissions and physician burnout. Tactics used to improve reliability include huddles, purposeful redundancy, and leadership engagement.
Field C, Finley E, Deutsch ES. PA-PSRS Pa Patient Saf Advis. 2019;16(1).
Rau J. Kaiser Health News. March 1, 2019.
Financial incentives may encourage adoption of practice improvements that enhance safety. This news article reports on the increase in United States hospitals that have had Medicare payments withheld due to high rates of hospital-acquired conditions. The article is accompanied by a state-level tally of individual hospitals penalized.
Dembosky A. All Things Considered and KQED. January 23, 2019.
Policy, practice, and communication strategies have been implemented in an effort to stem the opioid crisis and prescribing activities that contribute to misuse. This news article and accompanying webcast discuss an initiative in California that sends letters to prescribers whose patients have died due to opioid overdose. The piece outlines unintended consequences associated with the practice, including clinician reluctance to prescribe opioids for pain. An Annual Perspective discussed the patient safety aspects of the opioid epidemic.
Rau J. Kaiser Health News. December 3, 2018.
Beck DL. ASH Clinical News. December 1, 2018.
Wild D. Pharmacy Practice News. November 8, 2018.
Medication safety officers serve as organizational champions of medication management process improvement. This news article offers two examples of health care organizations that positioned medication safety officers as leaders in their systems. The piece describes improvements stemming from employment of medication safety officers at these organizations.
ISMP Medication Safety Alert! Acute Care Edition. November 1, 2018;23:1-5. November 15, 2018;23:1-5.
Errors in the administration of intravenous medications can result in patient harm. This set of articles discusses the results of a nationwide IV push medication survey. The first article reviews unsafe practices in care delivery as defined by inpatient clinicians. The second article recommends ways to improve practice such as assessment of current practices, use of prefilled syringes, and heightened attention to effective labeling.
Gipson K. PA-PSRS Pa Patient Saf Advis. 2018 Oct 31;15(suppl 1):39-45.
van der Heijde R, Deichmann D. Harv Bus Rev. October 30, 2018.
Aviation continues to provide inspiration for patient safety innovation. This commentary describes a 10-minute team huddle exercise which involves team members rating their own mood status and the leader asking if there are any contextual concerns. In addition, two team members select "knowledge cards" that either test the person's knowledge or assign the person to proactively watch for improvement opportunities during the shift. The results encouraged sharing, situational awareness, and team building.
Kaiser Health News.