Narrow Results Clear All
- Communication Improvement 4
- Culture of Safety 3
- Education and Training 3
- Error Reporting and Analysis 4
- Human Factors Engineering 11
- Legal and Policy Approaches 6
- Logistical Approaches 2
- Quality Improvement Strategies 6
- Specialization of Care 2
- Teamwork 2
- Technologic Approaches 7
- Device-related Complications 6
- Diagnostic Errors 1
- Discontinuities, Gaps, and Hand-Off Problems 1
- Medical Complications 8
- Medication Errors/Preventable Adverse Drug Events 7
- Psychological and Social Complications 3
- Second victims 1
- Surgical Complications 1
- Surgery 2
- Nursing 2
- Pharmacy 2
- Health Care Executives and Administrators 12
- Health Care Providers 13
- Non-Health Care Professionals 7
- Patients 13
Search results for "Newspaper/Magazine Article"
- Newspaper/Magazine Article
- Intensive Care Units
Safety enhancements every hospital must consider in wake of another tragic neuromuscular blocker event.
ISMP Medication Safety Alert! Acute Care Edition. January 17, 2019;24.
This newsletter article reports on the findings of a government investigation into the death of a patient during a positron emission tomography scan. A neuromuscular blocking agent was mistakenly administered instead of an anti-anxiety medication with a similar name. The investigation determined various individual and system failures that contributed to the incident, such as misuse of automated dispensing cabinets, wrong picklist medication selection, workarounds of override protections, and lack of patient monitoring. Recommendations for preventing similar incidents include use of barcoding verification, automated dispensing cabinet stocking changes, and labeling improvements.
McFarling UL. STAT. September 7, 2016.
Intensive care units (ICUs) are complex environments that harbor various challenges to safe care delivery. Reporting on alarm fatigue and insufficient interoperability between devices in ICUs, this news article describes solutions to address data overload and highlights the efforts of several hospitals working toward developing ICUs that are more respectful of patients and the clinical teams caring for them.
Sun LH. Washington Post. April 8, 2015.
Agnvall E. AARP. November 16, 2012.
Consumer Reports. January 26, 2012.
Consumer Reports analyzed publicly reported infection rates for 92 pediatric intensive care units (ICUs) and found that hospital-acquired infections were 20% higher in pediatric ICUs than in adult ICUs.
ISMP Medication Safety Alert! Acute Care Edition. July 14, 2011;16:1-3.
Graham J, Dizikes C. Chicago Tribune. June 27, 2011.
This newspaper article reports on an order entry error that resulted in a 60-fold overdose and raised concerns about the safety of electronic medication data systems.
Parents can detect, contribute to, or be affected by critical events during a child’s hospitalization.
ISMP Medication Safety Alert! Acute Care Edition. June 16, 2011;16:1-3.
This newsletter piece provides recommendations to strengthen parental involvement during a child's hospitalization.
ISMP Medication Safety Alert! Acute Care Edition. April 21, 2011;16:1-3.
This article analyzes a fatal error involving parenteral nutrition and makes recommendations to prevent such incidents.
Harasim P. Las Vegas Review-Journal. November 21, 2010;News:1B.
This article discusses how the organizational system of one hospital delayed an investigation into catheter line malfunctions.
Grant M. AARP The Magazine. September/October 2010;53:48-51,90-91.
Rojas-Burke J. The Oregonian. May 8, 2010.
This newspaper article describes how lessons from the Keystone ICU Project have reduced central line infections in Oregon hospitals.
Consumer Reports. March 2010;75:16-21.
Tremlett G. Guardian.co.uk; July 13, 2009.
This newspaper article reports on a family that experienced two medical errors, resulting in the death of both a mother and her infant.
Herzer K, Seshamani M. HealthReform.Gov. July 2009.
Yarbrough C, Rypkema S. Patient Safety & Quality Healthcare. January-February 2008;5:32-35.
This article describes how one Veterans Affairs hospital employed teamwork, checklists, and technology and successfully reduced hospital-acquired infections.
Gawande A. The New Yorker. December 10, 2007;83:86-95.
This article by bestselling author and surgeon Atul Gawande illustrates the complexity of intensive care and profiles Peter Pronovost, the Johns Hopkins intensivist and safety leader whose efforts to standardize safety practices led to remarkable reductions in ICU harm in Michigan hospitals. It goes on to a broader discussion of how checklists and decision support have reduced errors and transformed safety in critical care. Gawande also reflects on how implementation of standardized approaches often conflicts with the traditional physician culture, which prizes individual expertise over all else.
ISMP Medication Safety Alert! Acute Care Edition. September 6, 2007;12:1-4.
This article analyzes a lethal error involving TPN (total parenteral nutrition), in which dosing and compounding were based on incorrect order entry, and provides recommendations to prevent similar errors.
Graham J. Chicago Tribune. August 21, 2007;Metro section:1.
This article discusses a new Illinois state law that requires hospitals to screen all intensive care patients for methicillin-resistant Staphylococcus aureus (MRSA) infections and to isolate infected patients.
Naik G. Wall Street Journal. November 14, 2006:A1. [reprinted on Post-gazette.com].
This story describes how hospitals in the United Kingdom have incorporated teamwork principles used by auto racing pit crews to improve patient safety during handoffs.