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- Study 3
- Slideset 1
- Legislation/Regulation 4
- Newspaper/Magazine Article
- Special or Theme Issue 17
- Toolkit 1
- Web Resource 33
- Award 5
- Grant 1
Communication between Providers
- Sbar 4
- Communication between Providers 164
Culture of Safety
- Just Culture 11
Education and Training
- Simulators 17
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Error Reporting and Analysis
- Never Events 12
- Error Reporting 202
Human Factors Engineering
- Checklists 44
Legal and Policy Approaches
- Regulation 57
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Quality Improvement Strategies
- Benchmarking 16
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- Specialization of Care 51
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- Clinical Information Systems 124
- Transparency and Accountability 20
- Alert fatigue 4
- Device-related Complications 73
- Diagnostic Errors 104
- Discontinuities, Gaps, and Hand-Off Problems 102
- Drug shortages 19
- Failure to rescue 3
- Fatigue and Sleep Deprivation 22
- Identification Errors 52
- Interruptions and distractions 12
- Delirium 1
- Medication Errors/Preventable Adverse Drug Events 285
- MRI safety 4
- Nonsurgical Procedural Complications 25
- Overtreatment 5
- Psychological and Social Complications 80
- Second victims 8
- Surgical Complications 147
- Transfusion Complications 4
- Ambulatory Care 114
- Operating Room 103
- General Hospitals 208
- Long-Term Care 18
- Outpatient Surgery 18
- Patient Transport 8
- Psychiatric Facilities 6
- Allied Health Services 5
- Dentistry 1
- Geriatrics 21
- Obstetrics 24
- Pediatrics 52
- Primary Care 12
- Radiology 22
- Internal Medicine 312
- Nursing 71
- Palliative Care 1
- Pharmacy 204
- Family Members and Caregivers 39
- Health Care Executives and Administrators 641
Health Care Providers
- Nurses 100
- Pharmacists 93
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Non-Health Care Professionals
- Educators 40
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- Patients 557
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United States of America
United States Federal Government
- Department of Health and Human Services (HHS) 24
- United States Federal Government 30
Search results for "Newspaper/Magazine Article"
- Newspaper/Magazine Article
Partnering with families and patient advocates: another line of defense in adverse event surveillance.
ISMP Medication Safety Alert! Acute Care Edition. August 1, 2019;24.
Having family members or patient advocates present during hospitalizations can help prevent errors. This newsletter article suggests that utilizing this risk prevention strategy in peripheral care areas such as radiology and other testing units could also prevent patient harm. Recommendations to ensure success of this approach include communicating with advocates, encouraging them to speak up, and activating a rapid response to patient deterioration.
Quick Safety. July 15, 2019;(50):1-4.
This newsletter article discusses nurse burnout and how to reduce conditions that contribute to the problem. Recommendations focus on the role of leadership in fostering resilience, organizational strategies to enhance nurse empowerment, and frontline learning and regular measurement of staff perceptions of their well-being at work.
Colino S. Fam Circle. August 2019;132:66,69.
Patients and families can play a role in ensuring care is effective and safe. This news article recommends ways for patients to reduce risk of errors during a hospitalization, including using a patient portal to identify mistakes, asking questions, bringing an advocate, and working with hospitalists as key care partners.
Joseph R, Harry E. Medical Economics. June 27, 2019.
Multitasking can negatively affect cognitive load and diminish safety. This magazine article reports on how multitasking can contribute to surgeon fatigue, burnout, and decreased task completion in the perioperative environment. Checklists to automate workflow and limiting the number of patient charts that can be open at one time can help reduce extraneous cognitive load.
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.
Palmer J. Patient Saf Qual Healthc. May/June 2019.
Organizations must learn from adverse events to prevent similar incidents. Reporting on lessons to be learned from the cascade of failures connected with the preventable death of a patient during an acute asthma attack at the door of a hospital emergency department, this magazine article outlines the importance of effective signage, appropriate security staff placement, and acceptance of the responsibility for failure.
Jewett C. Kaiser Health News. May 3, 2019.
Transparency has been heralded as a cornerstone to improvement in health care. This news article reports on a government alternative summary reporting program that allowed medical device makers to conceal safety events and malfunction reports associated with medical devices. A new program that expands access to information about device-related failures will be put in place.
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.
Quick Safety. April 15, 2019;(48):1-3.
Fatigue, emotional stress, and illness can affect decision-making and lead to misuse of medications. This newsletter article describes the patient safety impacts of drug diversion among health care workers and notes the importance of a culture of constructive reporting to uncover and address this unsafe behavior.
Gordon M. Health Shots. National Public Radio. April 10, 2019.
Punitive responses to medical errors persist despite continued efforts to reduce them. This news article reports on an incident involving the mistaken use of a neuromuscular blocking agent that resulted in the death of a patient, the prosecution of the nurse who made the error, and systemic and human factors that contribute to similar events.
Erich J. EMS World. April 2019;48:26-31.
Air transport service combines risks associated with both aviation and prehospital trauma care. This article discusses the role of human factors in this fast-paced care environment. The author encourages efforts to reduce risks through policy change, purchasing the latest safety equipment, and empowering staff to decline calls when conditions are unsafe.
Field C, Finley E, Deutsch ES. PA-PSRS Pa Patient Saf Advis. 2019;16(1).