Narrow Results Clear All
- Communication Improvement 16
- Culture of Safety 9
- Education and Training 16
Error Reporting and Analysis
- Error Reporting 23
- Human Factors Engineering 24
Legal and Policy Approaches
- Regulation 10
- Logistical Approaches 5
- Quality Improvement Strategies 35
- Specialization of Care 10
- Teamwork 4
- Clinical Information Systems 4
- Transparency and Accountability 1
- Device-related Complications 13
- Diagnostic Errors 5
- Discontinuities, Gaps, and Hand-Off Problems 8
- Fatigue and Sleep Deprivation 1
- Identification Errors 8
- Delirium 1
- Medication Errors/Preventable Adverse Drug Events 11
- Nonsurgical Procedural Complications 1
- Psychological and Social Complications 2
- Surgical Complications 28
- Transfusion Complications 2
- Allied Health Services 3
- Internal Medicine 65
- Nursing 6
- Pharmacy 8
- Family Members and Caregivers 4
- Health Care Executives and Administrators 48
Health Care Providers
- Nurses 1
Non-Health Care Professionals
- Media 2
- Patients 70
- Europe 3
- Canada 2
Search results for "Newspaper/Magazine Article"
- Newspaper/Magazine Article
- Medical Complications
Frakt A. New York Times. April 29, 2019.
Health care providers are a known source of potentially harmful bacteria due to their perpetual interaction with germs during practice. This newspaper article reports on how clinician attire, stethoscopes, and technology can be contaminated with bacteria. Hand sanitizer placement, sleeve length, and laundering behaviors can reduce transmission of pathogens.
Rau J. Kaiser Health News. March 1, 2019.
Financial incentives may encourage adoption of practice improvements that enhance safety. This news article reports on the increase in United States hospitals that have had Medicare payments withheld due to high rates of hospital-acquired conditions. The article is accompanied by a state-level tally of individual hospitals penalized.
Rau J. Kaiser Health News. December 3, 2018.
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.
Peskin SM. New York Times. October 4, 2018.
Error disclosures are difficult but important conversations that can have negative consequences for patients, clinicians, and organizations, even when they are done appropriately. This newspaper article offers insights from a doctor who experienced both sides of disclosure, as a physician disclosing an error and as a patient whose physician missed a complication, and discusses how to manage relationships once clinical mistakes are recognized.
Decerbo M. Pharmacy Practice News. September 13, 2018.
Parenteral nutrition errors can result in patient malnutrition and harm. Reporting on how insufficient understanding of malnutrition contributes to its presence in health care, this news article suggests that both general guidelines and tailored approaches to nutrition are necessary to keep hospitalized patients safe. Improvements in addressing the complicated needs of patients who are older or have cancer illustrate progress made toward the effective delivery of nutrition.
Schulte F, Lucas E, Mahr J. Kaiser Health News and Chicago Tribune. September 5, 2018.
Sepsis is a serious condition that can be fatal if it is not promptly diagnosed and treated. This news article reports on systemic factors in nursing homes such as poor staffing and communication with families that contribute to unmanaged pressure ulcers and sepsis that result in hospital admissions and death. A WebM&M commentary discussed a case involving a patient who had a pressure ulcer and sepsis in long-term care.
Quick Safety. March 27, 2018;(40):1-2.
Falls are a common patient safety concern for adults but are rarely discussed as a threat to newborn safety. This newsletter article provides a definition for a newborn fall or drop, highlights factors that increase risks of such incidents, and offers recommendations to augment safety such as rounding to monitor parent fatigue and reporting of events to inform improvements.
Jewett C. Kaiser Health News. May 9, 2017.
The Centers for Medicare and Medicaid Services decision to withhold payment for certain hospital-acquired conditions has prompted widespread efforts to prevent such events. This news article reports on an evaluation by the Office of Inspector General that found regulator review of hospital-acquired infection reports submitted to Medicare to be insufficient, which hinders hospitals' ability to learn from factors that contribute to infections.
Two effective initiatives for C-suite leaders to improve medication safety and the reliability of outcomes.
ISMP Medication Safety Alert! Acute Care Edition. March 23, 2017;22:1-5.
Levine H. Consum Rep. 2017 Jan;82:32-40.
Hospital rating systems have yet to receive approval across the health care industry, but they still serve as a way for consumers to select hospitals and providers. This news article reports on publicly available data for central line infections in hospitals across the United States and spotlights checklists as a strategy that contributes to improvement. The article also ranks teaching hospitals based on their performance at preventing central line infections.
Branswell H. STAT. October 25, 2016.
McNeill R, Nelson DJ, Abutaleb Y. Reuters Investigation. September 7, 2016.
Antimicrobial resistance is a pervasive threat to patient safety. This news article discusses incidents involving methicillin-resistant Staphylococcus aureus (MRSA) infection to spotlight the need for health care to develop system-level approaches to measuring the problem and enforce regulations designed to prevent health care–associated infections. A PSNet perspective described one nurse's experience with MRSA as a patient.
CDC Vital Signs. August 23, 2016.
CDC Vital Signs. March 3, 2016.
Health care–associated infections (HAI) are a worldwide patient safety problem. This article and accompanying set of infographics spotlight the importance of addressing HAIs and provide updates on improvements associated with better use of catheters, appropriate patient isolation, and increased vigilance to reduce the risks of antibiotic-resistant infections.
Freyer FJ. Boston Globe. November 19, 2015.
Consumer Reports. July 29, 2015.
Boodman SG. The Atlantic. June 7, 2015.
Delirium is a common unintended consequence of hospitalization, most often following a surgical procedure. This magazine article discusses characteristics of the condition, contributing factors, challenges to diagnosing it, and strategies to reduce its incidence. A previous AHRQ WebM&M commentary describes the key diagnostic differences between delirium and dementia.
Daley J. Colorado Public Radio. February 17, 2015.
Patient and family stories of harm are increasingly promoted as a strategy to provide insights into medical errors. This radio segment interviews a patient advocate whose daughter died due to medical errors, including failure-to-rescue and a health care–associated infection, and who speaks about that experience to educate clinicians on the importance of patient safety and listening to patients' families.
Hospital Engagement Networks participants make big strides in reducing patient harm and readmissions.
Vesely R. Hosp Health Netw. November 2014;88:26-31.
The Hospital Engagement Network initiative serves as an example of engaging health care organizations in a large-scale collaborative effort to raise awareness of certain safety challenges and implement changes to address them. This magazine article reveals insights from hospitals involved in the initiative and reports results as compiled by its organizers, including reductions in early elective deliveries, pressure ulcers, central line–associated infections, ventilator-associated pneumonia, and readmissions.