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- WebM&M Cases 2
- Perspectives on Safety 2
- Study 4
- Slideset 1
- Book/Report 11
- Newspaper/Magazine Article 31
- Special or Theme Issue 2
- Toolkit 2
- Web Resource 15
- Award 1
- Grant 1
- Meeting/Conference 1
- Press Release/Announcement 7
- Communication Improvement 24
- Culture of Safety 9
Education and Training
- Students 1
Error Reporting and Analysis
- Error Reporting 19
- Human Factors Engineering 10
- Legal and Policy Approaches 13
- Logistical Approaches 2
- Quality Improvement Strategies 25
- Research Directions 1
- Specialization of Care 4
- Teamwork 3
- Technologic Approaches 17
- Transparency and Accountability 1
- Device-related Complications 8
- Diagnostic Errors 1
- Discontinuities, Gaps, and Hand-Off Problems 11
- Fatigue and Sleep Deprivation 1
- Identification Errors 9
- Medical Complications 13
- Medication Errors/Preventable Adverse Drug Events 47
- Nonsurgical Procedural Complications 4
- Psychological and Social Complications 1
- Surgical Complications 9
- Internal Medicine 10
- Pediatrics 10
- Surgery 3
- Nursing 5
- Pharmacy 18
- Family Members and Caregivers 4
- Health Care Executives and Administrators
Health Care Providers
- Nurses 7
Non-Health Care Professionals
- Media 4
- Australia and New Zealand 1
- Europe 9
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Search results for ""
Cases & Commentaries
- Web M&M
Dean Schillinger, MD; March 2004
A misunderstanding of instructions on how to administer medication leads to an infant choking on a syringe cap.
Cases & Commentaries
- Web M&M
Glenn Flores, MD; April 2006
With no one to interpret for them and pharmacy instructions printed only in English, nonEnglish-speaking parents give their child a 12.5-fold overdose of a medication.
Perspectives on Safety > Perspective
Organizational Change in the Face of Highly Public Errors—I. The Dana-Farber Cancer Institute Experience
with commentary by James B. Conway; Saul N. Weingart, MD, PhD, Errors in the Media and Organizational Change, May 2005
A decade ago, two tragic medical errors rocked one of the world’s great cancer hospitals, Dana-Farber Cancer Institute (DFCI) in Boston, to its core. The errors led to considerable soul searching and, ultimately, a major change in institutional practices a...
Perspectives on Safety > Perspective
with commentary by Rosemary Gibson, MSc, The Patient's Role in Safety, March 2007
Patients have three roles in improving patient safety: helping to ensure their own safety, working with health care organizations to improve safety at the organization and unit level, and advocating as citizens for public reporting and accountability of hospital and health system performance. The following case illustrates how patients can help ensure their own safety.
Doctor’s orders killed cancer patient: Dana-Farber admits drug overdose caused death of Globe columnist, damage to second woman.
Knox RA. The Boston Globe. March 23, 1995; Metro/Region section: 1.
This column chronicles the tragic death of Betsy Lehman, a Boston Globe health columnist, who fell victim to an inadvertent overdose of chemotherapy while receiving treatment for breast cancer at the Dana-Farber Cancer Institute. The story details the events surrounding the case, the reactions among family and the public, and the response from Dana-Farber.
Scanning out medication errors: Ohio Valley Hospital's automated IV system provides real-time access to patient data.
Carbasho T. Pittsburgh Business Times. April 25, 2005.
This article reports on Ohio Valley General Hospital's intravenous safety system. Using bar code scanning to provide important patient information, the system automates checks for intravenous medication administration.
Bull G. USA Today. April 28, 2005.
This article reports on Target pharmacies' redesign of prescription bottles. The new bottles, designed to support safer outpatient medication use, have a flattened label and are color-coded for each family member.
Saving lives: hospitals have signed on to a six-part plan to avoid a multitude of unnecessary deaths.
Comarow A. US News & World Report. July 18, 2005;139:74,76,79.
This article, accompanying the widely read ranking of "America's Best Hospitals," describes the Institute for Healthcare Improvement's 100,000 Lives Campaign. Focusing on the six practices promoted by the campaign, it reviews the progress to date, with a particular focus on two participating hospitals' (Hackensack University Medical Center in New Jersey and McLeod Regional Medical Center in South Carolina) experiences in implementing the practices.
Scobie S, Thomson R. London, England: National Patient Safety Agency; 2005.
Created in 2001 to institute changes in health care across the United Kingdom, the National Patient Safety Agency (NPSA) presents their first report of patient safety incidents. The two-part report begins with a general discussion of incident reporting, the basis for a national reporting system, and the development of the Patient Safety Observatory. The second part builds on this framework by discussing how the acquired data can be used and translated into safer health care strategies. The report itself encompasses more than 85,000 collected incident reports with analysis, comparisons, and case studies to illustrate important safety issues for future efforts. This represents the first of a series of expected reports from NPSA on patient safety data to be published.
Fischman J. US News and World Report. August 1, 2005;139:45,49-50,52.
This article reports on activities at several hospitals that illustrate how information technology can help improve the safety of health care.
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.
BBC News. August 9, 2005.
This article reports on a prototype electronic wristband that checks medications against a patient's prescription.
Szabo L. USA Today. August 23, 2005.
This article reports the announcement of an international initiative to share patient safety strategies. The initiative will be led by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).
Ostrom CM. Seattle Times. September 13, 2005;Local News:B3
This article reports on how one family and hospital will use personal tragedy to create awareness in practitioners of the importance of accurate labeling in hospitals.
Franklin D. New York Times. October 25, 2005:F1.
This article discusses an important health literacy and medication safety concern: the absence of standardization of colored warning labels applied to prescription bottles. Inconsistent messages, icons, and colors may cause confusion for consumers.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; May 21, 2009.
This announcement reports on potential for falsely elevated glucose readings in patients taking parenteral maltose, parenteral galactose, or oral xylose and provides a list of products that may interfere with glucose monitoring.
Meisel Z. Slate. November 8, 2005.
In this article, an emergency medicine physician describes the work environment of emergency medical technicians and paramedics and why it is prone to error.
Berwick DM. Newsweek. December 12, 2005;46:75-78.
Institute for Healthcare Improvement President Don Berwick summarizes the six improvement measures of the 100K Lives Campaign.
Dublin, Ireland: Irish Society for Quality & Safety in Healthcare; 2005.
This report provides results from a 26-hospital survey investigating areas of service and care weakness in Irish hospitals. The research revealed problems related to information transfer, overwork, and lack of patient involvement in decision making about their care.
Gray R. Scotland on Sunday. January 8, 2006.
This story discusses the impact of a computer glitch in a system used by more than 80% of general practitioners in Scotland. In addition to physician notes being inadvertently attached to the wrong patient's medical record, reports suggest that some patients actually received incorrect prescriptions due to printing errors caused by the system.