Narrow Results Clear All
- Communication Improvement 4
- Culture of Safety 1
- Education and Training 3
- Error Reporting and Analysis 3
- Human Factors Engineering 3
- Quality Improvement Strategies 4
- Technologic Approaches 2
- Device-related Complications 1
- Diagnostic Errors
- Discontinuities, Gaps, and Hand-Off Problems 2
- Interruptions and distractions 1
- Medical Complications 1
- Medication Safety 3
- Surgical Complications 1
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Cases & Commentaries
- Spotlight Case
- Web M&M
James G. Adams, MD; June 2003
Abdominal pain misdiagnosed in an ED patient leads to ruptured appendix, multiple complications, and prolonged hospitalization.
Cases & Commentaries
- Web M&M
Yi Lu, MD, PhD, and Douglas Salvador, MD, MPH; August 2019
A woman with a history of prior spine surgery presented to the emergency department with progressive low back pain. An MRI scan of T11–S1 showed lumbar degenerative joint disease and a small L5–S1 disc herniation. She was referred for physical therapy and prescribed muscle relaxant, non-steroidal anti-inflammatories, and pain relievers. Ten days later, she presented to a community hospital with fever, inability to walk, and numbness from the waist down. Her white blood cell count was greater than 30,000 and she was found to be in acute renal and liver failure. She was transferred to a neurosurgery service at an academic hospital when an MRI revealed a T6–T10 thoracic epidural abscess.
Patient Safety Primers
This Primer provides an overview of the history and current status of the patient safety field and key definitions and concepts. It links to other Patient Safety Primers that discuss the concepts in more detail.
Audiovisual > Audiovisual Presentation
Food and Drug Administration (FDA) Patient Safety News. Show #79. September 2008.
This collection of video segments offers information on common types of medical errors, particularly medication errors, based on reports to the Institute for Safe Medication Practices.
Special or Theme Issue
Health Aff (Millwood). 2018;37:1723-1908.
The Institute of Medicine report, To Err Is Human, marked the founding of the patient safety field. This special issue of Health Affairs, published 20 years after that report, highlights achievements and progress to date. One implementation study of evidence-based surgical safety checklists demonstrated that leadership involvement, intensive activities, and engagement of frontline staff are all critical to successful adoption of safety practices. Another study demonstrated that communication-and-resolution programs either decreased or did not affect malpractice costs, providing further support for implementing such programs. Experts describe the critical role of human factors engineering in patient safety and outline how to enhance the use of these methods. The concluding editorial by David Bates and Hardeep Singh points to progress in reducing hospital-acquired infections and improving medication safety in acute care settings and highlights remaining gaps in the areas of outpatient care, diagnostic errors, and electronic health record safety. In the related information, the Moore Foundation provides free access to five articles in this special issue.
Journal Article > Study
Missed opportunities for diagnosing brain tumours in primary care: a qualitative study of patient experiences.
Walter FM, Penfold C, Joannides A, et al. Br J Gen Pract. 2019;69:e224-e235.
This qualitative study of 39 patients with a recent diagnosis of brain tumor found that many had multiple primary care visits prior to diagnosis, raising concern for missed opportunities for diagnosis. Patients reported more prompt diagnosis when their primary care physician elicited a more comprehensive history including subtle cognitive changes. The authors conclude that better public awareness of symptoms could prompt more timely diagnosis of brain tumors.