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Communication between Providers
- Sbar 1
- Communication between Providers
- Culture of Safety 3
Education and Training
- Students 1
- Error Reporting and Analysis 12
- Human Factors Engineering 10
- Legal and Policy Approaches 10
- Logistical Approaches 7
- Quality Improvement Strategies 13
- Specialization of Care 2
- Teamwork 10
- Clinical Information Systems 11
- Alert fatigue 1
- Device-related Complications 1
- Diagnostic Errors 8
- Discontinuities, Gaps, and Hand-Off Problems 22
- Failure to rescue 1
- Fatigue and Sleep Deprivation 1
- Identification Errors 18
- Medical Complications 3
- Medication Safety 20
- Nonsurgical Procedural Complications 1
- Psychological and Social Complications 7
- Surgical Complications 18
- Transfusion Complications 1
- Internal Medicine 14
- Pharmacy 7
- Family Members and Caregivers 3
- Health Care Executives and Administrators 23
Health Care Providers
- Nurses 5
- Physicians 14
- Non-Health Care Professionals 15
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Cases & Commentaries
- Web M&M
Russ Cucina, MD, MS; July 2006
Despite full documentation and a wristband regarding her severe food allergy, an inpatient is advertently fed eggs and suffers an allergic reaction.
Cases & Commentaries
- Spotlight Case
- Web M&M
Brittany McGalliard, PharmD; Rita Shane, PharmD; and Sonja Rosen, MD; September 2016
An elderly woman with multiple medical conditions experienced new onset dizziness and lightheadedness. A home visit revealed numerous problems with her medications, with discontinued medications remaining in her pillbox and a new prescription that was missing. In addition, on some days she was taking up to five blood pressure pills, when she was supposed to be taking only two.
Perspectives on Safety > Interview
The Patient's Role in Safety, March 2007
Sorrel King is the mother of Josie King, who died tragically in 2001 at age 18 months because of medical errors during a hospitalization at Johns Hopkins Hospital. She has subsequently become one of the nation’s foremost patient advocates for safety, forming an influential foundation (the Josie King Foundation) and partnering with Johns Hopkins to promote the field of patient safety around the world.
Journal Article > Study
Porter SC, Kohane IS, Goldmann DA. J Am Med Inform Assoc. 2005;12:299-305.
This study examined the utility of a multimedia kiosk to capture parents' knowledge of their children's asthma medication history. Investigators compared the parental information with that documented by emergency department providers. Results suggested greatest accuracy in medication name followed by route of delivery, form of medication, and dose. The authors conclude that patient-derived data can be effective in improving current deficits in medication documentation during emergency department visits.
Young D. Am J Health Syst Pharm. 2005;62:1340-1342.
This article summarizes comments made at the second meeting of the Committee on Identifying and Preventing Medication Errors. Topics covered include teamwork, engaging patients, medication reconciliation, access to information, and hospital design.
Journal Article > Commentary
Sachs BP. JAMA. 2005;294:833-840.
Part of a series in JAMA entitled Clinical Crossroads, this case study discusses the unfortunate events surrounding a 38-year-old woman's presentation to a labor and delivery unit. The case details a seemingly routine full-term pregnancy that rapidly evolved into a course of complications, ultimately leading to a fetal death, a hysterectomy, and a prolonged hospital course. The discussion shares the experience through the eyes of the patient, her husband, and the primary obstetrician. Further exploration of the case identified several specific factors and broader systems issues that contributed to the events. The author shares how this particular institution responded with overarching changes, including a greater emphasis on teamwork, communication, and appropriate staffing of labor and delivery units to promote safety.
Institute for Healthcare Improvement Web site. March 20, 2006.
This article reviews the importance of medication reconciliation, discusses the difficulties of building the process into patient care, and shares stories from hospitals that have successfully implemented programs.
Legislation/Regulation > Multi-use Website
The Joint Commission.
According to an AHRQ-supported study, wrong-site surgery occurred at a rate of approximately 1 per 113,000 operations between 1985 and 2004. In July 2004, The Joint Commission enacted a Universal Protocol that was developed through expert consensus on principles and steps for preventing wrong-site, wrong-procedure, and wrong-person surgery. The Universal Protocol applies to all accredited hospitals, ambulatory care, and office-based surgery facilities. The protocol requires performing a time out prior to beginning surgery, a practice that has been shown to improve teamwork and decrease the overall risk of wrong-site surgery. This Web site includes a number of resources and facts related to the Universal Protocol. Wrong-site, wrong-procedure, and wrong-patient errors are all now considered never events by the National Quality Forum and sentinel events by The Joint Commission. The Centers for Medicare and Medicaid Services have not reimbursed for any costs associated with these surgical errors since 2009.
Brody H. Am Fam Physician. 2006;73:1272, 1274.
This article presents a case scenario of an unacknowledged misdiagnosis discovered through a patient's request for a second opinion. The author discusses how the colleague who discovered the mistake should address the first physician's denial of error.
Bernhard B. The Orange County Register. April 19, 2006.
This article reports on an Anaheim anesthesiologist's pre-surgery checklist, inspired by similar checklists used in the aviation industry.
Landro L. Wall Street Journal (Eastern edition). May 23, 2006:D1. [reprinted on Post-Gazette.com]
This article discusses the shared responsibility among patients, hospitals, and practitioners to support appropriate drug administration through medication reconciliation.
Stout D. New York Times. June 17, 2006;National desk:9.
This article reports on the investigation following the death of New York Times reporter David E. Rosenbaum. The investigation uncovered a range of failures in emergency care and is described in a report available via the link below.
Landro L. Wall Street Journal (Eastern edition). June 28, 2006:D1. [reprinted on Post-gazette.com].
This article reports on communication interventions such as SBAR (Situation-Background-Assessment-Recommendation) that make patient hand-offs more reliable.
Landro L. Wall Street Journal. July 12, 2006:D1. [Reprinted on Post-gazette.com].
This article reports on efforts to reduce use of certain medications and instruments that can cause harm during labor and delivery.
Committee on Identifying and Preventing Medication Errors, Aspden P, Wolcott J, Bootman JL, Cronenwett LR, eds. Washington, DC: The National Academies Press; 2007.
A major report by the Institute of Medicine (IOM) on medication errors suggests that, despite all the progress in patient safety since To Err is Human, medication errors remain extremely common, and the health care system can do much more to prevent them. Among the startling statistics from this report: more than 1.5 million Americans are injured every year in American hospitals, and the average hospitalized patient experiences at least one medication error each day. The report emphasizes actions that health care systems, providers, funders, and regulators can take to improve medication safety. These actions include having all US prescriptions written and dispensed electronically by 2010, more widespread use of medication reconciliation, and additional research on drug errors and how to prevent them. Importantly, the report also emphasizes actions that patients can take to prevent medication errors, such as maintaining active medication lists and bringing their medications to appointments. Support for the IOM report came from the Centers for Medicare & Medicaid Services.
Bramson K, Mooney T. Providence Journal. August 18, 2006.
This article reports on a case of mistaken identity that resulted in erroneous surgery, despite a "time out" before beginning the operation.
Journal Article > Commentary
The author explains the Joint Commission on Accreditation of Healthcare Organizations' Universal Protocol on surgical site verification in the context of its implementation in a New Jersey hospital.
Gledhill V. The Evening Chronicle. January 25, 2007;News section:9.
This article reports on a patient death caused by medical omission and the communication failures that occurred with both the family and regulatory body after the incident.
Bohan S. Oakland Tribune. January 27, 2007.
This article describes how simulators are being used by hospitals to train medical teams on effective communication and teamwork.
Markel H. New York Times. February 25, 2007;4:5.
This article discusses the problems associated with taking many prescription and over-the-counter medications, as dangerous combinations may go undetected.