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Palmer J. Patient Saf Qual Healthc. May/June 2019.
Organizations must learn from adverse events to prevent similar incidents. Reporting on lessons to be learned from the cascade of failures connected with the preventable death of a patient during an acute asthma attack at the door of a hospital emergency department, this magazine article outlines the importance of effective signage, appropriate security staff placement, and acceptance of the responsibility for failure.
Journal Article > Commentary
Chiu RG. AMA J Ethics. 2019;21:E553-E558.
Although disclosure of medical error to patients is difficult, it is an ethical responsibility. This article discusses situations involving patients who are incapacitated and unrepresented but have no surrogate present to assist in communication and care coordination. Despite this challenge, the author argues that the clinician and organization still have the responsibility to document what happened, communicate what is known, and rectify the mistake.