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Communication between Providers
- Sbar 1
- Communication between Providers 6
- Culture of Safety 1
- Education and Training 3
- Error Reporting and Analysis 4
- Human Factors Engineering 2
- Legal and Policy Approaches
- Logistical Approaches 3
- Quality Improvement Strategies 6
- Specialization of Care 1
- Technologic Approaches 1
- Device-related Complications 1
- Diagnostic Errors 1
- Discontinuities, Gaps, and Hand-Off Problems
- Fatigue and Sleep Deprivation 2
- Identification Errors 5
- Interruptions and distractions 1
- Medical Complications 3
- Medication Safety 6
- Psychological and Social Complications 2
- Surgical Complications 2
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Cases & Commentaries
- Web M&M
Joan M. Teno, MD, MS; April 2008
Despite having a signed DNR (do not resuscitate) form, an elderly man brought to the emergency department with severe pain was rushed to the operating room for urgent abdominal aortic aneurysm repair.
Perspectives on Safety > Perspective
with commentary by Arpana R. Vidyarthi, MD; Robert B. Baron, MD, MS, Medical Education and Patient Safety, February 2010
Clear health communication is increasingly recognized as essential for promoting patient safety. Yet according to a recent Joint Commission report, What Did the Doctor Say? Improving Health Literacy to Protect Patient Safety, communication problems among health care providers, patients, and families are common and a leading root cause of adverse outcomes.(1) Addressing health literacy—the capacity of individuals to obtain, process, and understand basic health information and services needed to make appropriate health decisions—has become a primary objective for many health systems in order to protect patients from harm.
Perspectives on Safety > Interview
Medical Education and Patient Safety, February 2010
Thomas J. Nasca, MD, is the executive director and chief executive officer of the Accreditation Council for Graduate Medical Education (ACGME). Prior to joining the ACGME in 2007, Dr. Nasca, a nephrologist, was dean of Jefferson Medical College and Senior Vice President for Academic Affairs of Thomas Jefferson University. We asked him to speak with us about the role of the ACGME in patient safety.
Landro L. Wall Street Journal (Eastern edition). June 28, 2006:D1. [reprinted on Post-gazette.com].
This article reports on communication interventions such as SBAR (Situation-Background-Assessment-Recommendation) that make patient hand-offs more reliable.
Breast Cancer Services in Trafford and North Manchester. An Investigation Into The Circumstances Surrounding A Serious Clinical Incident In Symptomatic Breast Services – The Baker Report.
Baker M. Manchester, England: NHS North West; February 2007.
This report shares findings from an investigation into individual and system failures that contributed to a radiologist misreading mammograms for a 2-year period.
Wolfe W. Minneapolis Star Tribune. February 28, 2007.
This article reports on three patient deaths due to errors at a state-owned nursing home for veterans.
Oakbrook Terrace, IL: The Joint Commission; March 2007.
This report reveals that the overall quality of care delivered by US hospitals improved steadily between 2003 and 2005, as measured by adherence to evidence-based treatments for myocardial infarction, congestive heart failure, and pneumonia. Adherence to the Joint Commission's National Patient Safety Goals, which include measures to prevent wrong-site surgery and promote medication reconciliation, was also measured. Although results on these measures showed a more mixed picture, the report cautions that changes in measurement during the study period limit interpretability of the results.
Journal Article > Study
Scott-Cawiezell J, Pepper GA, Madsen RW, Petroski G, Vogelsmeier A, Zellmer D. Clin Nurs Res. 2007;16:72-78.
This study investigated whether type of credentials affected rates of medication errors and found no significant difference. However, the authors noted that nurses were interrupted more often during medication administration.
Kowalczyk L. Boston Globe. April 21, 2007:B1.
This article reports on the results from Joint Commission site inspections of five Boston-area hospitals.
Journal Article > Commentary
Dekker S. J Law Med Ethics. 2007;35:463-470.
The author analyzes one Swedish medication error incident that resulted in criminal charges against the nurse involved and discusses how the media contorted the assignment of blame for the failure.
Sydney, Australia: Australian Commission on Safety and Quality in Health Care; 2008. ISBN: 9780980346275.
This report compiles public and private data to provide insight into the quality and safety of patient care in Australian hospitals.
Web Resource > Multi-use Website
The Joint Commission.
The Joint Commission has traditionally focused on accreditation of health care organizations and, through its Joint Commission Resources arm, on quality improvement (QI) in areas related to its accreditation functions. In the first major initiative under the leadership of new president Dr. Mark Chassin, The Joint Commission launched this Center, which will focus on applying rigorous QI methods to improve safety in a number of challenging areas (the first three are hand hygiene, handoff communication, and preventing wrong site surgery) and disseminating the lessons from these efforts. This Web site provides more information about the Center and its goals.
Audiovisual > Audiovisual Presentation
Washington, DC: American Association for Clinical Chemistry.
Journal Article > Study
Unintentional discontinuation of chronic medications for seniors in nursing homes: evaluation of a national medication reconciliation accreditation requirement using a population-based cohort study.
Stall NM, Fischer HD, Wu CF, et al. Medicine (Baltimore). 2015;94:e899.
This study established that unintentional medication discontinuation upon nursing home admission decreased over time, though this improvement could not be attributed to accreditation requirements for medication reconciliation or any other specific intervention. This study highlights the challenge of attributing safety improvements to specific policy or practice changes.