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- Communication between Providers 39
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- Error Reporting and Analysis 29
- Human Factors Engineering 59
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- Quality Improvement Strategies 41
- Specialization of Care 10
- Teamwork 7
- Clinical Information Systems 123
- Transparency and Accountability 2
- Alert fatigue 3
- Device-related Complications 14
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- Discontinuities, Gaps, and Hand-Off Problems 21
- Drug shortages 1
- Failure to rescue 1
- Fatigue and Sleep Deprivation 1
- Identification Errors 12
- Interruptions and distractions 5
- Medical Complications 13
- Medication Errors/Preventable Adverse Drug Events 95
- Psychological and Social Complications 5
- Second victims 2
- Surgical Complications 16
- Transfusion Complications 2
- Internal Medicine 53
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- Pharmacy 70
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- Health Care Executives and Administrators 126
Health Care Providers
- Nurses 17
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Non-Health Care Professionals
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- Patients 83
Search results for "Newspaper/Magazine Article"
- Newspaper/Magazine Article
- Technologic Approaches
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.
Schulte F, Fry E. Kaiser Health News, Fortune Magazine. March 18, 2019.
Despite years of investment and government support, electronic health records (EHR) continue to face challenges as a patient safety strategy. This news article outlines the unintended consequences of EHR implementation, including patient harm linked to software glitches and user errors, fraudulent behavior (upcoding), interoperability problems, clinician burnout due to poorly designed digital health records, and lack of industry transparency.
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.
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.
Cierniak KH, Gaunt MJ, Grissinger M. PA-PSRS. Patient Saf Advis. 2018;15(4).
The operating room environment harbors particular patient safety hazards. Drawing from 1137 perioperative medication error reports submitted over a 1-year period, this analysis found that more than half of the recorded incidents reached the patient and the majority of those stemmed from communication breakdowns during transitions or handoffs. The authors provide recommendations to reduce risks of error, including using barcode medication administration, standardizing handoff procedures, and stocking prefilled syringes.
Gawande A. New Yorker. November 12, 2018.
In this magazine article, Atul Gawande describes a range of frustrations physicians experience as digitization becomes more widespread in health care. He elaborates upon several elements of electronic health record use that can degrade care processes and create conditions for errors, such as burnout, lack of patient-centeredness, and alert fatigue.
Parikh R. MIT Technol Rev. October 23, 2018.
Computerized decision support and artificial intelligence (AI) are being utilized to enhance decision-making in health care. This magazine article explains how artificial intelligence presents clinicians with an opportunity to improve practice by reducing cognitive load when determining appropriate diagnoses and treatment decisions.
Mix-ups between epidural analgesia and IV antibiotics in labor and delivery units continue to cause harm.
ISMP Medication Safety Alert! Acute Care Edition. October 4, 2018;23:1-4.
Increased urgency to prevent maternal mortality has uncovered various factors that diminish safety. This newsletter article reports on incidents involving the accidental misuse of epidural analgesia and intravenous antibiotics in labor and delivery care, describes contributing factors (e.g., health technology missteps, barcoding mistakes, and look-alike medications), and offers improvement strategies to mitigate harm.
Quick Safety. October 1, 2018;(45):1-2.
This newsletter article reviews common problems related to patient identification and recommends strategies to ensure verification actions are a part of daily practice. Highlighted suggestions focus on system-level approaches that reduce the potential for incorrect patient data to be entered and proliferate, such as use of frontline confirmation processes and duplicate record monitoring. A WebM&M commentary discussed an incident involving a wrong-patient order in an electronic record system.
Sederstrom J. Drug Topics. September 17, 2018.
Medication errors continue to be a worldwide patient safety challenge that requires both systems and individual practice strategies for improvement. This magazine article describes how pharmacists can address failures associated with processing, dosing, care transitions, and information sharing to prevent medication errors.
Arndt RZ. Mod Healthc. July 14, 2018.
Similarities in patient names and clinical situations can result in medical errors. Discussing how digital technologies can exacerbate patient identification problems, this magazine article describes unique elements of information systems that enable mistakes to spread quickly, outlines costs associated with patient mismatches, and recommends improvement strategies such as use of unique patient identifiers. A past WebM&M commentary reviewed an incident involving a patient mix-up.
The Economist. June 7, 2018.
Artificial intelligence (AI) can improve the timeliness and accuracy of decision making in health care. This magazine article reports on how AI use in medicine can affect diagnosis of cancers, stroke, and cardiac arrhythmia. The piece underscores that though these improvements may look impressive, human knowledge will still be necessary to achieve the full benefit of AI applications for health care improvement.
Burt A, Volchenboum S. Harv Bus Rev. May 8, 2018.
Porter S. HealthLeaders Media. April 26, 2018.
Overreliance on technology can result in harmful medication mistakes. Reporting on a 10-fold medication overdose that led to the death of a patient with dementia, this news article describes how the hospital changed their processes to improve medication safety, which included restructuring medication safety leadership, modifying the electronic health record to address alert overrides, and enhancing information sharing to support learning and transparency.
ISMP Medication Safety Alert! Acute Care Edition. April 5, 2018;23:1-5.
Smart pumps are considered an important tool to improve medication safety in the hospital environment. This newsletter article summarizes the results of two national surveys on smart infusion pump use to highlight current concerns and challenges to generating improvements. Irrelevant alarms and out-of-date drug libraries were among the problems identified by survey participants.
Wachter R, Goldsmith J. Harv Bus Rev. March 30, 2018.
Increased workload associated with electronic health record (EHR) documentation contributes to physician burnout. Describing challenges associated with poor user interface of EHRs, this magazine article recommends use of artificial intelligence, redesigning workflow, and enhancing alert systems to improve the usefulness of EHRs.
Lamas D. New York Times. March 27, 2018.
Advance care planning can affect patient safety if the information is unheeded, unavailable, or unread. Reporting on a physician's experience with a patient who nearly received an unwanted intubation due to poor electronic health record data quality and design, this newspaper article describes problems associated with lack of standards for advance care planning documentation and the inability to access advance directives.
Boodman SG. Washington Post. March 26, 2018.
Although providing patients with access to physician notes and test results supports transparency and patient engagement, it can also introduce certain challenges. This newspaper article reports on unintended psychological stresses associated with direct patient access to test results without appropriate contextual information. Improvement strategies include use of graphics, timely patient-centered communication, and scheduling appointments to discuss results. A PSNet perspective explored how patient-facing technologies can empower patients and improve safety.
Liberatore K. PA-PSRS Patient Saf Advis. 2018 March;15.
Latex products are widely available in hospitals and represent a persistent threat to patients with latex allergies. Drawing from 616 reported latex-related events, this investigation found that more than half of the incidents were associated with indwelling urinary catheter use. Tracking staff awareness of latex allergies, purchasing latex-safe alternatives, and improving handoff documentation of patient allergies are possible risk reduction strategies. A WebM&M commentary discussed allergy documentation in patient health records.
Meyer TA, McAllister RK. Pharmacy Practice News. March 19, 2018.
Perioperative adverse drug events are common and understudied. Reporting on the complexity of medication administration during surgery, this news article reviews strategies to reduce risks of surgical adverse drug events. Specific tactics discussed include proactive problem identification, medication reconciliation, high-alert medication process vigilance, verbal order reduction, and information technology optimization.