Narrow Results Clear All
- Communication Improvement 5
- Culture of Safety 2
- Education and Training 1
- Error Reporting and Analysis 15
- Human Factors Engineering 2
- Logistical Approaches 1
- Quality Improvement Strategies 2
- Technologic Approaches 3
- Device-related Complications 1
- Discontinuities, Gaps, and Hand-Off Problems 2
- Identification Errors 1
- Medical Complications 1
- Medication Safety 9
- Psychological and Social Complications 1
- Surgical Complications 2
- Family Members and Caregivers 2
- Health Care Executives and Administrators 14
Health Care Providers
- Nurses 2
- Non-Health Care Professionals 7
- Patients 1
Search results for "Newspaper/Magazine Article"
- Newspaper/Magazine Article
- Near Miss
Cierniak KH, Gaunt MJ, Grissinger M. PA-PSRS. Patient Saf Advis. 2018;15(4).
The operating room environment harbors particular patient safety hazards. Drawing from 1137 perioperative medication error reports submitted over a 1-year period, this analysis found that more than half of the recorded incidents reached the patient and the majority of those stemmed from communication breakdowns during transitions or handoffs. The authors provide recommendations to reduce risks of error, including using barcode medication administration, standardizing handoff procedures, and stocking prefilled syringes.
Magee MC, Miller K, Patzek D, Madera C, Michalek C, Shetterly M. PA-PSRS Patient Saf Advis. December 2017;14.
Near misses provide unique opportunities to identify and learn from safety hazards. Describing how one organization utilized data on near misses involving barcode medication administration over a 12-year period to reduce barcode-workflow events, this report outlines practices and strategies that contributed to success such as promoting event reporting and applying root cause analysis.
Wallace SC, Mamrol C, Finley E. PA-PSRS Patient Saf Advis. September 2017;14.
Near misses or good catches present organizations with learning opportunities. Using data comparisons run by the Pennsylvania Patient Safety Authority, this article highlights how good catch programs can contribute to significant reductions in harmful events and offers insights from risk managers and patient safety officers regarding elements that are necessary to establish successful good catch initiatives and the culture to support them.
Traynor K. Am J Health Syst Pharm. 2015;72:1597-1599.
ISMP Medication Safety Alert! Acute Care Edition. November 20, 2014;19:1-3.
Reviewing an incident involving a patient who reported an error with home infusion of chemotherapy which was later determined to be a false alarm, this newsletter article outlines actions that could have been taken to prevent wasted resources and anxiety for the patient and health care providers.
Connor M, Wayman KI, Garcia C, Fischer PR; Consortium for Maximizing Family-Centered Care. Patient Saf Qual Healthc. September/October 2014;11:36,38-40,42.
Patients are increasingly encouraged to take an active role in their own safety during hospital care. Describing a near miss of a medication error, this magazine article examines elements of effective disclosure and how engaging patients and their families can contribute to error investigations and safety improvement.
Clark C. HealthLeaders Media. November 5, 2013.
This article summarizes an annual report that spotlights health technologies that may lead to patient harm.
Clark C. HealthLeaders Media. December 2012.
Yasgur BS. Medscape Business of Medicine. December 6, 2012.
McCook A. Anesthesiology News. Sept 2011;37:9.
This news article highlights a program at Johns Hopkins Medicine that engages clinician reporting of errors and near misses to improve patient safety.
Sun LH. Washington Post. August 2, 2011.
This newspaper article reports on one hospital's implementation of an alert system designed to encourage frontline personnel to report close calls.
ISMP Medication Safety Alert! Acute Care Edition. September 23, 2010;15,1-6.
This piece explores the effects of drug shortages on patient safety and provides examples of resulting near misses, errors, and adverse outcomes.
DerGurahian J. Mod Healthc. December 7, 2009.
This article reports on accomplishments in patient safety since the To Err Is Human report was released.
Crocker C. Nurs Times. 2009 Nov 24;105:12-15.
This article tracks the care of a United Kingdom National Health Service patient and identifies several areas for process improvement to ensure safe medication delivery.
Grant T. Washington Post. July 22, 2008:HE01
This article reports on a wrong-sided surgery near miss from the perspective of a parent, and discusses the role of family members in preventing medical errors.
Marella WM. Patient Saf Qual Healthc. Sept/Oct 2007;4:22-26.
The author describes the collection and management of information on near misses as well as using such data to support learning opportunities for hospital staffs.
Freeman L. Naples Daily News. January 13, 2007.
This article reports on the progress of the Florida Patient Safety Corporation and its near miss reporting initiative.
Ostrom CM. The Seattle Times. May 21, 2005.
This article reports how one medical center changed their preoperative procedures after a "near miss." The hospital's patient-safety approach is designed to openly identify and evaluate incidents to prevent future mistakes.