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- Education and Training 3
- Error Reporting and Analysis 4
- Human Factors Engineering 1
- Legal and Policy Approaches
- Logistical Approaches 1
- Quality Improvement Strategies 3
- Technologic Approaches 1
- Device-related Complications 1
- Discontinuities, Gaps, and Hand-Off Problems 1
- Identification Errors 1
- Medical Complications
- Medication Safety 1
- Surgical Complications 4
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Cases & Commentaries
- Spotlight Case
- Web M&M
Sumant Ranji, MD; April 2008
A woman with symptoms of sinusitis was given 2 different courses of broad-spectrum antibiotics, neither of which improved her symptoms. Hospitalized for autoimmune hemolysis (presumably from the antibiotic), the patient suffered multiorgan failure and septic shock, and died.
World Health Organization.
This publication shares news related to the World Health Organization's Global Patient Safety Challenge.
Consumer Reports. January 26, 2012.
Consumer Reports analyzed publicly reported infection rates for 92 pediatric intensive care units (ICUs) and found that hospital-acquired infections were 20% higher in pediatric ICUs than in adult ICUs.
Snyderman N. NBC News. February 22, 2012.
This news video reports how inadequate sterilization of surgical instruments can affect patient safety.
Landro L. Wall Street Journal. June 5, 2012;D1.
This newspaper article describes how one hospital reduced hospital-acquired infection rates.
Eisler P. USA Today. August 16, 2012.
This newspaper article reports on how clinicians, hospitals, and health care systems can reduce incidence of hospital-acquired Clostridium difficile infections.
Kolata G. New York Times. August 22, 2012.
Despite strict infection controls placed around a patient carrying a deadly antibiotic-resistant bacteria, 17 other patients also became infected and 6 died. This newspaper article details the approach used to track the chain of transmission.
Grady D, Pollack A, Tavernise S. New York Times. October 6, 2012.
This newspaper article discusses how the drug shortage and use of compounded drugs contributed to an outbreak of fungal meningitis in the United States. The outbreak has already led to more than a dozen deaths.
Cohen E. CNN. October 15, 2012.
This news piece reports on a patient who may have been misdiagnosed with a stroke after receiving a contaminated steroid injection.
Ryan J. All Things Considered. National Public Radio. October 16, 2013.
This radio news segment reports on patient falls, including risk factors and prevention strategies.
Bernhard B, Kohler J. St. Louis Post-Dispatch. August 1, 2010:A1
In the context of system failures that contributed to the death of a patient, this newspaper article describes how never events are rarely publicized, even though hospital inspection reports are public records.
Teegardin C. Atlanta Journal-Constitution. April 28, 2013.
Hartcollis A. New York Times. May 29, 2013:A18.
This newspaper article reports on efforts, such as remote video monitoring or distributing "red cards," to improve hand hygiene compliance in hospitals.
Is your hospital really as safe as you think? Our updated hospital safety score can help you find out.
Consumer Reports. March 27, 2014.
Despite lack of consensus on the value of comparative hospital safety scores, they continue to generate interest and discussion around safety improvement efforts. This news article reports one analysis of patient safety in United States hospitals using five federal measures of safety: mortality, readmission, computed tomography scanning, hospital-acquired infections, and communication regarding medications and discharge planning.
Catalanello R. The Times-Picayune. April 15, 2014.
O'Donnell J. USA Today. August 6, 2014.
This newspaper article reports on changes to publicly reported data on the Hospital Compare Web site. Several avoidable hospital-acquired conditions, such as air embolism or retained foreign objects, are no longer included. Working with the National Quality Forum, the Centers for Medicare and Medicaid Services (CMS) decided to modify the list to make it easier for consumers to use and understand.
Rodricks D. Baltimore Sun. October 14, 2014.
Although significant progress has been made in improving patient safety over the past decade, many medical errors continue to occur. In light of the recent incident involving transmission of the Ebola virus from a patient to a nurse at a Dallas hospital, this newspaper article reports on how lapses in following standard procedures in care environments, such as insufficient handwashing, can result in preventable harm.
Gubar S. New York Times. October 30, 2014.
This newspaper article describes how surgical complications, health care–associated infections, and ineffective patient–provider communication contributed to a patient's experience with harm and suggests that transparency around the incident and preoperative patient briefings could have improved the situation.