Narrow Results Clear All
- Communication Improvement
- Culture of Safety 1
- Education and Training 3
- Error Reporting and Analysis 4
- Human Factors Engineering 3
- Legal and Policy Approaches 3
- Quality Improvement Strategies 2
- Technologic Approaches 1
- Device-related Complications 1
- Discontinuities, Gaps, and Hand-Off Problems 2
- Identification Errors 1
- Medical Complications 2
- Medication Safety
- Psychological and Social Complications 1
- Surgical Complications 1
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Cases & Commentaries
- Web M&M
Albert W. Wu, MD, MPH; Peter J. Pronovost, MD, PhD; January 2004
A patient receiving end-of-life care, whose code status was DNR, encounters a potentially life-threatening medication error.
Perspectives on Safety > Interview
Health Literacy and Safety, February-March 2009
Dean Schillinger, MD, is a Professor of Medicine at University of California, San Francisco, Director of the UCSF Center for Vulnerable Populations, and Chief of the California Diabetes Prevention and Control Program. His role as a practicing clinician at a safety net hospital (San Francisco General Hospital) has put him in a unique position to pursue influential and relevant research related to health literacy and improving care for vulnerable populations.
Journal Article > Commentary
Armitage G. J Clin Nurs. 2005;14:869-875.
In this position paper, the author considers the ethical issues involved in error research at National Health Service hospitals.
Oakbrook Terrace, IL: The Joint Commission; 2007.
Low health literacy is a recognized patient safety problem. Prior research has demonstrated that patients with impaired health literacy have difficulty comprehending prescription instructions and warnings. This Joint Commission report, developed by an expert panel, contains specific recommendations for improving provider–patient communication, in order to ameliorate the problem of low health literacy as much as possible. The report recommends that organizations establish communication as a patient safety priority and calls for financial support for patient-centered care initiatives.
Journal Article > Study
Kernisan LP, Lee SJ, Boscardin WJ, Landefeld CS, Dudley RA. JAMA. 2009;301:1341-1348.
The Leapfrog Group has been a major driver of patient safety efforts—more than 1000 hospitals have committed to implementing its recommendations for computerized provider order entry, intensivist coverage for critically ill patients, evidence-based referral for certain diagnoses, and implementation of the National Quality Forum's (NQF) Safe Practices. A prior study found that hospitals that had implemented at least one Leapfrog practice tended to provide higher quality of care for specific diagnoses. However, in this study, adoption of the NQF safe practices did not correlate with reduced inpatient mortality. The authors note that many hospitals could score highly on the Leapfrog Hospital Survey but not fully implement or consistently follow safety recommendations, as the survey only measures a hospital's self-reported implementation of safety practices.
McCook A. Anesthesiology News. Sept 2011;37:9.
This news article highlights a program at Johns Hopkins Medicine that engages clinician reporting of errors and near misses to improve patient safety.