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- Study 3
- Slideset 1
- Legislation/Regulation 4
- Newspaper/Magazine Article
- Special or Theme Issue 17
- Toolkit 1
- Web Resource 32
- Award 5
- Grant 1
Communication between Providers
- Sbar 4
- Communication between Providers 162
Culture of Safety
- Just Culture 10
Education and Training
- Simulators 17
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Error Reporting and Analysis
- Never Events 12
- Error Reporting 199
Human Factors Engineering
- Checklists 43
Legal and Policy Approaches
- Regulation 57
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Quality Improvement Strategies
- Benchmarking 16
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- Specialization of Care 48
- Teamwork 51
- Clinical Information Systems 122
- Transparency and Accountability 17
- Alert fatigue 3
- Device-related Complications 72
- Diagnostic Errors 104
- Discontinuities, Gaps, and Hand-Off Problems 101
- Drug shortages 19
- Failure to rescue 1
- Fatigue and Sleep Deprivation 22
- Identification Errors 51
- Interruptions and distractions 11
- Delirium 1
- Medication Errors/Preventable Adverse Drug Events 281
- MRI safety 4
- Nonsurgical Procedural Complications 23
- Overtreatment 5
- Psychological and Social Complications 77
- Second victims 8
- Surgical Complications 145
- Transfusion Complications 4
- Ambulatory Care 111
- Operating Room 100
- General Hospitals 202
- Long-Term Care 18
- Outpatient Surgery 18
- Patient Transport 7
- Psychiatric Facilities 6
- Allied Health Services 5
- Dentistry 1
- Geriatrics 21
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- Pediatrics 50
- Primary Care 12
- Radiology 21
- Internal Medicine 310
- Nursing 70
- Palliative Care 1
- Pharmacy 203
- Family Members and Caregivers 34
- Health Care Executives and Administrators 628
Health Care Providers
- Nurses 98
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Non-Health Care Professionals
- Educators 39
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- Patients 550
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United States of America
United States Federal Government
- Department of Health and Human Services (HHS) 23
- United States Federal Government 29
Search results for "Newspaper/Magazine Article"
- Newspaper/Magazine Article
Gordon M. Health Shots. National Public Radio. April 10, 2019.
Punitive responses to medical errors persist despite continued efforts to reduce them. This news article reports on an incident involving the mistaken use of a neuromuscular blocking agent that resulted in the death of a patient, the prosecution of the nurse who made the error, and systemic and human factors that contribute to similar events.
Field C, Finley E, Deutsch ES. PA-PSRS Pa Patient Saf Advis. 2019;16(1).
Schulte F, Fry E. Kaiser Health News, Fortune Magazine. March 18, 2019.
Despite years of investment and government support, electronic health records (EHR) continue to face challenges as a patient safety strategy. This news article outlines the unintended consequences of EHR implementation, including patient harm linked to software glitches and user errors, fraudulent behavior (upcoding), interoperability problems, clinician burnout due to poorly designed digital health records, and lack of industry transparency.
Dickson EJ. Rolling Stone. March 9, 2019.
Unintended consequences of restrictions enacted to combat the opioid crisis are a concern for patients and prescribers. This magazine article reports on an effort to raise awareness of the potential for patient harm due to lack of legitimate access to opioids for chronic pain as a result of the 2016 CDC opioid prescribing guidelines.
Rau J. Kaiser Health News. March 1, 2019.
Financial incentives may encourage adoption of practice improvements that enhance safety. This news article reports on the increase in United States hospitals that have had Medicare payments withheld due to high rates of hospital-acquired conditions. The article is accompanied by a state-level tally of individual hospitals penalized.
ISMP Medication Safety Alert! Acute Care Edition. February 28, 2019;24.
Medication warnings inform providers and patients about risks associated with medication use. As with other safety strategies, applying a systems approach to medication warnings can help redirect actions and prevent patient harm. This article describes design, content, and language characteristics of successful medication safety warnings. In addition, specific design and user-centered considerations are included to improve the effectiveness of electronic alerting.
Chisholm P. Health Shots. National Public Radio. February 27, 2019.
Another round of the blame game: a paralyzing criminal indictment that recklessly "overrides" just culture.
ISMP Medication Safety Alert! Acute Care Edition. February 14, 2019;24.
Span P. New York Times. February 1, 2019.
Cognitive and functional decline can occur as individuals age. Concerns have been raised regarding the need to assess skills of aging physicians. This newspaper article reports on the implementation of mandatory evaluation programs to assess competencies of older surgeons and the profession's response to them.
Janik LS, Vender JS Grissinger M, Litman RS. APSF Newsletter. February 2019;33:72-75.
This pair of commentaries reviews the use of color-coded medications as an anesthesia safety strategy. The first article argues for implementing standard color sets to delineate drug class and use to improve medication safety. The dissenting article suggests that color-coded medications may decrease the chance of clinicians reading syringe labels carefully due to overreliance on color representation as a shortcut for reading the label.
Hixenbaugh M, Ornstein C. Houston Chronicle and Propublica.
This news investigation chronicles a series of incidents in a transplant program that resulted in patient harm. The systemic nature of the problems such as insufficient whistleblower protection, accountability, and follow-up on patient concerns culminated in a change of hospital leadership. A previous PSNet interview with Charles Ornstein discussed the role of media in raising awareness of patient safety issues.
Park A. Time Magazine. January 24, 2019.
This news article reports on the documentary To Err Is Human, which was produced and directed by the son of patient safety leader Dr. John M. Eisenberg. The film is structured around patient safety advocate Sue Sheridan's experience with diagnostic errors that resulted in harm for both her son and husband. It features a wide range of experts who discuss the impact of error on all involved, the role of culture in facilitating both mistakes and progress, and why continued work in health care safety is needed.
Dembosky A. All Things Considered and KQED. January 23, 2019.
Policy, practice, and communication strategies have been implemented in an effort to stem the opioid crisis and prescribing activities that contribute to misuse. This news article and accompanying webcast discuss an initiative in California that sends letters to prescribers whose patients have died due to opioid overdose. The piece outlines unintended consequences associated with the practice, including clinician reluctance to prescribe opioids for pain. An Annual Perspective discussed the patient safety aspects of the opioid epidemic.
Safety enhancements every hospital must consider in wake of another tragic neuromuscular blocker event.
ISMP Medication Safety Alert! Acute Care Edition. January 17, 2019;24.
This newsletter article reports on the findings of a government investigation into the death of a patient during a positron emission tomography scan. A neuromuscular blocking agent was mistakenly administered instead of an anti-anxiety medication with a similar name. The investigation determined various individual and system failures that contributed to the incident, such as misuse of automated dispensing cabinets, wrong picklist medication selection, workarounds of override protections, and lack of patient monitoring. Recommendations for preventing similar incidents include use of barcoding verification, automated dispensing cabinet stocking changes, and labeling improvements.
Cierniak KH, Gaunt MJ, Grissinger M. PA-PSRS. Patient Saf Advis. 2018;15(4).
The operating room environment harbors particular patient safety hazards. Drawing from 1137 perioperative medication error reports submitted over a 1-year period, this analysis found that more than half of the recorded incidents reached the patient and the majority of those stemmed from communication breakdowns during transitions or handoffs. The authors provide recommendations to reduce risks of error, including using barcode medication administration, standardizing handoff procedures, and stocking prefilled syringes.
Rau J. Kaiser Health News. December 3, 2018.
Beck DL. ASH Clinical News. December 1, 2018.
ISMP Medication Safety Alert! Acute Care Edition. November 29, 2018;23:1-6.
Look-alike and sound-alike medications present a recurring threat to patient safety. This newsletter article summarizes an analysis of reported drug name confusion errors. Although incidents seem to have decreased over time, the influx of generic drug names is contributing to the persistence of the problem. Increased federal attention to the issue, provider use of known strategies to improve practice, and pharmaceutical company testing of names to avoid similarities can help reduce drug name confusion.
McGrory K, Bedi N. Tampa Bay Times. November 28, 2018.
Mohr H, Weiss M. Associated Press. November 27, 2018.