Narrow Results Clear All
- 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 117
Education and Training
- Simulators 17
- Students 10
Error Reporting and Analysis
- Never Events 12
- Error Reporting 199
Human Factors Engineering
- Checklists 43
Legal and Policy Approaches
- Regulation 57
- Logistical Approaches 72
- Policies and Operations 10
Quality Improvement Strategies
- Benchmarking 16
- Reminders 11
- Specialization of Care 48
- Teamwork 51
- Clinical Information Systems 121
- Transparency and Accountability 17
- Alert fatigue 3
- Device-related Complications 72
- Diagnostic Errors 103
- 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 280
- MRI safety 4
- Nonsurgical Procedural Complications 23
- Overtreatment 5
- Psychological and Social Complications 76
- Second victims 7
- 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
- Obstetrics 22
- Pediatrics 50
- Primary Care 12
- Radiology 19
- Internal Medicine 310
- Nursing 68
- Palliative Care 1
- Pharmacy 203
- Family Members and Caregivers 31
- Health Care Executives and Administrators 623
Health Care Providers
- Nurses 98
- Pharmacists 93
- Physicians 192
Non-Health Care Professionals
- Educators 38
- Engineers 40
- Media 9
- Patients 545
- Asia 1
- Europe 41
- Canada 13
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
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.
Graham J. Kaiser Health News. November 21, 2018.
Patients can identify errors in their medical records that health care providers may not recognize. This news article highlights the importance of patients correcting seemingly simple mistakes such as name misspellings and phone numbers as these errors can contribute to situations that result in patient harm.
Simmons-Ritchie D. Penn Live. November 15, 2018.
Nursing home patients are vulnerable to preventable harm due to poor safety culture, insufficient staffing levels, lack of regulation enforcement, and misaligned financial incentives. This news investigation reports on how poor practices resulted in resident harm in Pennsylvania nursing homes and discusses strategies for improvement, such as enhancing investigation processes.
Wild D. Pharmacy Practice News. November 8, 2018.
Medication safety officers serve as organizational champions of medication management process improvement. This news article offers two examples of health care organizations that positioned medication safety officers as leaders in their systems. The piece describes improvements stemming from employment of medication safety officers at these organizations.
DeMarco P. Globe Magazine. November 3, 2018.
This magazine article reports on the preventable death of a patient during an acute asthma attack. Written by the patient's husband, the article outlines the failures that led to her death despite the fact that she was at the door of a hospital emergency department and on the phone with an emergency dispatcher. Factors discussed include overreliance on poorly functioning technology, communication failures, and lack of fail-safes.
Gawande A. New Yorker. November 12, 2018.
In this magazine article, Atul Gawande describes a range of frustrations physicians experience as digitization becomes more widespread in health care. He elaborates upon several elements of electronic health record use that can degrade care processes and create conditions for errors, such as burnout, lack of patient-centeredness, and alert fatigue.
ISMP Medication Safety Alert! Acute Care Edition. November 1, 2018;23:1-5. November 15, 2018;23:1-5.
Errors in the administration of intravenous medications can result in patient harm. This set of articles discusses the results of a nationwide IV push medication survey. The first article reviews unsafe practices in care delivery as defined by inpatient clinicians. The second article recommends ways to improve practice such as assessment of current practices, use of prefilled syringes, and heightened attention to effective labeling.
Gipson K. PA-PSRS Pa Patient Saf Advis. 2018 Oct 31;15(suppl 1):39-45.
van der Heijde R, Deichmann D. Harv Bus Rev. October 30, 2018.
Aviation continues to provide inspiration for patient safety innovation. This commentary describes a 10-minute team huddle exercise which involves team members rating their own mood status and the leader asking if there are any contextual concerns. In addition, two team members select "knowledge cards" that either test the person's knowledge or assign the person to proactively watch for improvement opportunities during the shift. The results encouraged sharing, situational awareness, and team building.