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- Communication between Providers 17
Culture of Safety
- Just Culture 11
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- Students 1
- Error Reporting and Analysis 35
- Human Factors Engineering 17
- Legal and Policy Approaches 17
- Logistical Approaches 8
- Policies and Operations 1
- Quality Improvement Strategies 39
- Specialization of Care 5
- Teamwork 15
- Clinical Information Systems 8
- Transparency and Accountability 4
- Device-related Complications 5
- Diagnostic Errors 3
- Discontinuities, Gaps, and Hand-Off Problems 6
- Drug shortages 1
- Identification Errors 8
- Medical Complications 9
- Medication Errors/Preventable Adverse Drug Events 13
- Nonsurgical Procedural Complications 2
- Psychological and Social Complications 4
- Second victims 3
- Surgical Complications 15
- Internal Medicine 31
- Nursing 4
- Pharmacy 6
- Family Members and Caregivers 3
- Health Care Executives and Administrators 95
Health Care Providers
- Nurses 8
- Physicians 13
Non-Health Care Professionals
- Media 1
- Patients 26
Search results for "Newspaper/Magazine Article"
- Newspaper/Magazine Article
- Culture of Safety
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.
Another round of the blame game: a paralyzing criminal indictment that recklessly "overrides" just culture.
ISMP Medication Safety Alert! Acute Care Edition. February 14, 2019;24.
Park A. Time Magazine. January 24, 2019.
This news article reports on the documentary To Err Is Human, which was produced and directed by the son of patient safety leader Dr. John M. Eisenberg. The film is structured around patient safety advocate Sue Sheridan's experience with diagnostic errors that resulted in harm for both her son and husband. It features a wide range of experts who discuss the impact of error on all involved, the role of culture in facilitating both mistakes and progress, and why continued work in health care safety is needed.
McGrory K, Bedi N. Tampa Bay Times. November 28, 2018.
Simmons-Ritchie D. Penn Live. November 15, 2018.
Nursing home patients are vulnerable to preventable harm due to poor safety culture, insufficient staffing levels, lack of regulation enforcement, and misaligned financial incentives. This news investigation reports on how poor practices resulted in resident harm in Pennsylvania nursing homes and discusses strategies for improvement, such as enhancing investigation processes.
Canadian Medical Protective Association. CMPA Perspective. September 2018;10:8-11.
Frontline leadership should model just culture behaviors to encourage reporting and discussion of error to facilitate improvement. This news article uses a medical administration error to examine whether human error, at-risk behavior, or reckless action on the part of a clinician led to the mistake and explores leadership response to the incident to determine accountability in each type of situation.
Students have a key role in a culture of safety: analysis of student-associated medication incidents.
ISMP Medication Safety Alert! Acute Care Edition. July 26, 2018;23:1-4.
Previous studies have discussed concerns associated with new clinician involvement in care delivery. This data analysis highlights how organizational culture affects student-related errors and summarizes the positive contribution students bring to medication safety, including new perspectives, recently acquired evidence, and a willingness to ask questions.
Gale SF. Chief Learning Officer. July/August 2018;17:22-25.
Rau J. Kaiser Health News. June 13, 2018.
Safety problems are common in nursing homes due to challenges such as poor safety culture, staff burnout, and inappropriate polypharmacy. Describing how medication missteps and communication errors can diminish safety of residential care, this news article discusses system-level incentives that can either contribute to avoidable hospital readmissions of long-term care patients or be employed to improve practice.
The science of safety: trustees can play a crucial role in fostering a safety culture at their hospitals.
Fairbanks RJ, Krevat SA. Trustee Magazine. January 8, 2018.
Safety sciences offer methods to enhance processes and develop organizational culture. This magazine article reports on safety science approaches that have improved safety in high-risk industries and concepts such as learning from failure and transparency that should be encouraged by leadership in health care.
Two effective initiatives for C-suite leaders to improve medication safety and the reliability of outcomes.
ISMP Medication Safety Alert! Acute Care Edition. March 23, 2017;22:1-5.
Clements K. Nurs Manage. 2017;48:12-13.
Selected medication safety risks to manage in 2016 that might otherwise fall off the radar screen—part 1 and part 2.
ISMP Medication Safety Alert! Acute Care Edition. January 28, 2016;21:1-4. February 11, 2016;21:1-5.
Traynor K. Am J Health Syst Pharm. 2015;72:1597-1599.
Eid KA. Nursing. 2015;45:14-16.
Robust processes that enable review and analysis of medical errors are critical to support organizational learning. This commentary highlights one institution's experience convening a multidisciplinary committee focused on improving medication administration through analysis of medication-related incidents and implementing interventions based on the group's findings.
Butcher L. Trustee Magazine. June 8, 2015.
Board member and health care executive commitment is important for establishing a culture of safety. This magazine article features insights from hospital leaders that have achieved success in their organizations' adoption of safety culture through engaging leadership, setting goals, and incorporating high-reliability principles.
Birk S. Healthc Exec. March/April 2015;30:19-20, 22-26.
Hospital senior managers have been challenged to establish a safety culture in their organizations. This magazine article reveals how three hospitals developed a culture of safety by focusing their improvement work on high reliability principles through leadership engagement, training, and teamwork.
ISMP Medication Safety Alert! Acute Care Edition. July 31, 2014;
This article introduces the concept of mindfulness within the context of principles of high reliability organizations.
Leslie I. New Statesman. June 4, 2014.
This magazine article reports on the experience of a pilot whose wife died due to a medical error. In response to learning about the chain of events that led to her death and how it could have been prevented, he committed to applying aviation safety concepts such as crew resource management and human factors to improve health care safety.