Narrow Results Clear All
- WebM&M Cases 1
- Perspectives on Safety 2
- Review 1
- Study 8
- Audiovisual 9
- Book/Report 17
- Newspaper/Magazine Article 29
- Special or Theme Issue 3
- Toolkit 1
- Web Resource 6
- Award 1
- Meeting/Conference 1
- Communication Improvement 22
- Culture of Safety 8
- Education and Training 12
Error Reporting and Analysis
- Error Reporting 16
- Human Factors Engineering 4
- Legal and Policy Approaches 16
- Logistical Approaches 2
- Quality Improvement Strategies 13
- Research Directions 1
- Teamwork 2
- Technologic Approaches 8
- Transparency and Accountability 2
- Device-related Complications 2
- Diagnostic Errors 12
- Discontinuities, Gaps, and Hand-Off Problems 6
- Fatigue and Sleep Deprivation 1
- Identification Errors 2
- Medical Complications 8
- Medication Errors/Preventable Adverse Drug Events 13
- Nonsurgical Procedural Complications 3
- Psychological and Social Complications 4
- Surgical Complications 4
- Internal Medicine 12
- Nursing 1
- Pharmacy 10
- Family Members and Caregivers 5
- Health Care Executives and Administrators 35
- Health Care Providers 46
Non-Health Care Professionals
- Media 2
Search results for ""
Cases & Commentaries
- Web M&M
Tejal K. Gandhi, MD, MPH; October 2003
Switched urine specimens lead to a patient receiving the wrong answer about her pregnancy test.
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...
Perspectives on Safety > Perspective
with commentary by Rosemary Gibson, MSc, The Patient's Role in Safety, March 2007
Patients have three roles in improving patient safety: helping to ensure their own safety, working with health care organizations to improve safety at the organization and unit level, and advocating as citizens for public reporting and accountability of hospital and health system performance. The following case illustrates how patients can help ensure their own safety.
van Vuuren W. [dissertation]. Eindhoven, The Netherlands: Eindhoven University of Technology; 1998.
This report provides a detailed review of risk management in complex and high-risk organizations. The author focuses on the analysis and categorization of safety-related incidents and their organizational causes.
Audiovisual > Audiovisual Presentation
Schiff G. "Eight Forty-Eight." Chicago Public Radio. October 16, 2004.
Quality and honesty play an influential role in the safety and cost of medical care. Gordon Schiff, the director of clinical and quality research (Department of Medicine at Stoger Hospital, Chicago, Illinois), explains how research findings helped uncover the hidden costs associated with making and then hiding medical error. The interview runs 13 minutes.
Casey SM. Santa Barbara, CA: Aegean Publishing Company; 1998. ISBN 13: 9780963617880.
This book introduces important human factors issues using a series of real cases and incidents from health care and a variety of other industries. The title refers to the disastrous death of a patient due to a design flaw in the radiotherapy accelerator, Therac-25. A plausible but unanticipated series of keystrokes by the operator resulted in the delivery of more than 100 times the intended dose of radiation. Other chapters discuss events as diverse as the Union Carbide disaster in Bhopal, India, an incorrect stock trade that nearly caused a market collapse, a variety of military and industrial examples, as well other cases from health care. The book provides numerous real-world examples of misadventures in human–system interactions.
Journal Article > Study
Cohn F, Rudman WJ. Jt Comm J Qual Saf. 2004;30:636-646.
Web Resource > Multi-use Website
The Joint Commission, Joint Commission Resources.
The center advocates for patient safety through research and education. Their Web site offers patient safety resources and sentinel event alerts.
Journal Article > Study
Competition and health plan performance: evidence from health maintenance organization insurance markets.
Scanlon DP, Swaminathan S, Chernew M, Bost JE, Shevock J. Med Care. 2005;43:338-346.
This study of 341 health maintenance organizations found that plans in markets with greater competition showed inferior performance on three of six standard quality measures. While the cross-sectional design does not permit causal inferences, these findings argue against the frequently encountered view that greater competition will foster improvements in safety and quality of care.
Youngberg BJ, ed. Jones & Bartlett Learning: Sudbuery MA; 2013. ISBN: 9780763774042.
This revised edition of a comprehensive resource on patient safety includes new chapters discussing such topics as the complexity of defining error and the need for medical and nursing education to develop leadership skills to help drive improvement efforts.
Berntsen KJ. Westport, CT: Praeger; 2004. ISBN: 0275982300.
The author provides an introduction to issues affecting safety in health care for a consumer audience. The text is interspersed with relevant stories from patients and tips to minimize opportunities for failure.
Journal Article > Study
Stewart D, Helms P, McCaig D, Bond C, McLay J. Br J Clin Pharmacol. 2005;59:677-683.
The investigators issued questionnaires to parents in seven community pharmacies to prospectively monitor pediatric adverse drug reactions (ADRs). They found that the system was effective for reporting ADRs.
Journal Article > Review
Aftermath of an adverse event: supporting health care professionals to meet patient expectations through open disclosure.
Manser T, Staender S. Acta Anaesthesiol Scand. 2005;49:728-734.
The authors explain elements of successful disclosure, including how health care organizations can encourage it.
Gaul GM. The Washington Post. July 29, 2005:A06.
This article presents the newly passed Patient Safety and Quality Improvement Act of 2005 in comparison to mandatory, state-based reporting initiatives.
Ostrom CM. Seattle Times. September 13, 2005;Local News:B3
This article reports on how one family and hospital will use personal tragedy to create awareness in practitioners of the importance of accurate labeling in hospitals.
Berenson RA. The New Republic. October 10, 2005;233:17-21.
To illustrate the need for malpractice tort reform, transparency, and fair compensation for patients, this article discusses individual stories, such as that of Susan Sheridan, whose son and husband were both injured by medical error, as well as organizational and grassroots efforts, such as the Sorry Works! Coalition.
Golden, CO: Health Grades, Inc.; April 2006.
This third annual report on the safety of hospitalized Medicare patients builds on past efforts to evaluate hospital performance. The report uses the Agency for Healthcare Research and Quality's Patient Safety Indicators to provide benchmarks for such performance, identify current trends in safety issues, and estimate preventable events nationally. The report suggests that the patient safety incidents captured account for more than $9 billion in excess cost during 2002-2004, and more than 250,000 potentially preventable deaths occurred during the same time period. Grading for all states and a selected group of highly rated hospitals is included with the implication that, if all hospitals performed at a level comparable to the ones acknowledged, more than 44,000 Medicare deaths could be avoided with a costs savings of $2.45 million. As with the second annual report, several methodological limitations exist, and the reports themselves did not receive external peer review.
Mirror, Mirror on the Wall: An Update on the Quality of American Health Care Through the Patient's Lens.
Davis K, Schoen S, Schoenbaum SC, et al. New York, NY: The Commonwealth Fund; April 2006.
This report presents findings from a cross-national survey of consumer views of health care. Findings are presented based on the aims for quality care outlined in Crossing the Quality Chasm and reveal that the United States has low rankings from the patient perspective when compared with the other five countries profiled.
Gibbs N, Bower A. Time Magazine. May 1, 2006.
This article takes an unusual look at the problem of medical errors: the perspective of physicians when they or a loved one is the patient. Even physicians well versed in the safety field find that they have relatively little control over the hospital environment and few ways to make their care safer. As the cover piece of Time magazine, this article is likely to generate considerable public discussion.
Journal Article > Commentary
Jost TS. Wake Forest Law Rev. 2006;41:537-618.
The author discusses problems in the U.S. health care system and laws that govern this system and provides a legal framework for reform.