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- Communication Improvement
- Education and Training 3
- Error Reporting and Analysis 2
- Policies and Operations 1
- Quality Improvement Strategies 2
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- Transparency and Accountability 1
- Health Care Executives and Administrators 5
- Health Care Providers 6
- Non-Health Care Professionals 4
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Perspectives on Safety > Annual Perspective
with commentary by Rachel J. Stern, MD, and Urmimala Sarkar, MD, 2018
Patient engagement is widely acknowledged as a cornerstone of patient safety. Research in 2018 demonstrates that patient engagement, when done correctly, can help health care systems identify safety hazards, regain trust after they occur, and codesign sustainable solutions.
Tools/Toolkit > Multi-use Website
Johns Hopkins University, Department of Anesthesiology & Critical Care Medicine.
This Web site provides information on the multidisciplinary safety team at Johns Hopkins University, including research projects, presentations, and useful tools for patients, families, and practitioners.
Special or Theme Issue
Paasche-Orlow MK, Wilson EAH, McCormack L, eds. J Health Comm. 2010;15(suppl 2):1-225.
This special issue presents findings from a 2009 conference that explored health literacy research in areas such as measurement improvement, informed consent, and organizational communication.
Journal Article > Study
Law AC, Roche S, Reichheld A, et al. Jt Comm J Qual Patient Saf. 2019;45:276-284.
Emotional and psychological harm are understudied but common preventable adverse events. Overt disrespect from health care providers and the lasting psychological impact of safety hazards both contribute to emotional harm. This large, prospective study explored emotional harm among 1559 family members of intensive care unit patients at a hospital in Boston, Massachusetts. About 22% of family members reported inadequate respect toward either themselves or the patient, and more than half of respondents perceived a lack of control over their loved one's care. Inadequate respect and lack of control were strongly correlated with overall satisfaction with care. A WebM&M commentary discussed the utility of family-centered care to preventing harm in the intensive care unit.
Journal Article > Commentary
Schiff GD, Martin SA, Eidelman DH, et al. Ann Intern Med. 2018;169:643-645.
Safe diagnosis is a complex challenge that requires multidisciplinary approaches to achieve lasting improvement. The authors worked with a multidisciplinary panel to build a 10-element framework outlining steps that support conservative diagnosis as an approach to reducing overdiagnosis and overtreatment.
Journal Article > Commentary
Hong K, Hong YD, Cooke CE. Res Social Adm Pharm. 2019;15:823-826.
Medication errors are common in inpatient and ambulatory environments. This commentary summarizes the research exploring the current status of medication safety incident reporting and reduction efforts in community pharmacies. The authors call for community pharmacy corporations to encourage the discussion and data sharing needed to increase transparency around incidents in this care setting. A recent PSNet interview discussed challenges to safety in the retail pharmacy environment.
Journal Article > Review
A systematic review of falls in hospital for patients with communication disability: highlighting an invisible population.
Hemsley B, Steel J, Worrall L, et al. J Safety Res. 2019;68:89-105.
This systematic review of falls among individuals with speech, language, and voice disability found that these populations are often excluded from studies of falls. However, there is some evidence that communication disability leads to increased risk of falls and the authors call for further study for this population.