Narrow Results Clear All
- Communication Improvement 1
- Culture of Safety 2
- Education and Training 5
- Error Reporting and Analysis 8
- Human Factors Engineering 3
- Legal and Policy Approaches
- Logistical Approaches 4
- Quality Improvement Strategies 5
- Technologic Approaches 2
- Transparency and Accountability 1
- Diagnostic Errors 10
- Discontinuities, Gaps, and Hand-Off Problems 4
- Drug shortages 2
- Fatigue and Sleep Deprivation 2
- Medical Complications 10
- Medication Errors/Preventable Adverse Drug Events 7
- Overtreatment 1
- Psychological and Social Complications 3
- Surgical Complications 1
- Internal Medicine
- Nursing 3
- Pharmacy 1
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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.
Perspectives on Safety > Perspective
Organizational Change in the Face of Highly Public Errors—I. The Dana-Farber Cancer Institute Experience
with commentary by James B. Conway; Saul N. Weingart, MD, PhD, Errors in the Media and Organizational Change, May 2005
A decade ago, two tragic medical errors rocked one of the world’s great cancer hospitals, Dana-Farber Cancer Institute (DFCI) in Boston, to its core. The errors led to considerable soul searching and, ultimately, a major change in institutional practices a...
Scathing report on Kaiser kidney program. Transplant delays assailed -- Medicare threatens to end coverage.
Russell S. San Francisco Chronicle. June 24, 2006.
This article reports on a Centers for Medicare & Medicaid Services report that details deficiencies in Kaiser's kidney transplant program.
World Health Organization.
This publication shares news related to the World Health Organization's Global Patient Safety Challenge.
Journal Article > Study
Hinchcliff R, Westbrook J, Greenfield D, Baysari M, Moldovan M, Braithwaite J. Int J Qual Health Care. 2012;24:1-8.
Vaida B. The Washingtonian. January 27, 2012.
This magazine article discusses patient safety improvement efforts as well as challenges hindering more widespread error reduction.
Rau J. Washington Post. February 12, 2012:A03.
This news article describes problems with analyzing data from a 2011 report on hospital-acquired conditions to accurately measure a hospital's overall quality of care.
Journal Article > Study
High-profile investigations into hospital safety problems in England did not prompt patients to switch providers.
Laverty AA, Smith PC, Pape UJ, Mears A, Wachter RM, Millett C. Health Aff (Millwood). 2012;31:593-601.
While medical errors continue to affect patients on a daily basis, most organizations fear high-profile cases that land on front pages of newspapers or lead to extensive regulatory intervention. This study evaluated the role of England's Care Quality Commission in their own regulatory investigation of major issues occurring in three hospitals. The investigations led to considerable media attention, but whether this influenced patient behavior was unknown. The authors found that the investigations had zero impact on utilization at two of the hospitals. The third experienced a decrease in inpatient admissions and new patient visits, but the effect dissipated 6 months following the public report. In an era of greater transparency and increased attention on patient safety, these findings suggest that patients' decision-making is perhaps less influenced than expected by such events. Two past AHRQ WebM&M perspectives discussed organizational change in the face of highly public errors at Duke and the Dana Farber Cancer Institute.
Greider K. AARP Bulletin. March 2012;53:10,12,14.
The Joint Commission. March 13, 2012.
The Eisenberg Award honors individuals and organizations who have made vital accomplishments in improving patient safety and quality. The 2011 honorees are Kenneth I. Shine, MD; Jerod M. Loeb, PhD; The Society of Hospital Medicine, Philadelphia, Pennsylvania; New York-Presbyterian Hospital, New York, New York; and Henry Ford Health System, Detroit, Michigan.
Willams B. The Record. March 10, 2012.
Exploring how drug shortages affect patients, this news piece describes one cancer patient's efforts to acquire the chemotherapeutic agent that is prolonging his life.
Sanders L. New York Times Magazine. March 18, 2012.
This interactive magazine feature takes readers through the decision-making process in a case involving diagnostic error.
Gupta S. New York, NY: Grand Central Publishing; 2012. ISBN: 9780446583855.
To illustrate how physicians learn from mistakes, this novel (written by CNN medical correspondent Dr. Sanjay Gupta) explores the impact of a medical error on surgeons at one hospital.
Landro L. Wall Street Journal. June 5, 2012;D1.
This newspaper article describes how one hospital reduced hospital-acquired infection rates.
Miller R. News-Times. July 25, 2012.
This newspaper article details the complications and errors a patient experienced following a routine surgery.
Gupta S. CNN. July 23, 2012.
This news video reports on how drug shortages affect patients and describes US Food and Drug Administration (FDA) efforts to address the issue.
Hartocollis A. New York Times. July 28, 2012.
This newspaper article reports on the missteps that contributed to the death of a young woman after she was hospitalized in an incident reminiscent of Libby Zion.
Terhune C. Los Angeles Times. August 3, 2012:B1.
This newspaper article reports on an incident during which dozens of hospitals lost access to electronic medical records (EMRs) and discusses risks associated with EMR systems.
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.