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- Communication Improvement
- Culture of Safety 2
- Education and Training 1
- Error Reporting and Analysis 2
- Human Factors Engineering 2
- Legal and Policy Approaches 1
- Logistical Approaches 1
- Quality Improvement Strategies 5
- Teamwork 2
- Technologic Approaches 1
- Transparency and Accountability 1
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Cases & Commentaries
- Web M&M
Catherine McLean, MD; March 2005
At a routine clinic visit, screening labs are sent for a man with HIV. Not notified of the results, he assumes they are normal. One month later, he develops a classic syphilitic rash.
Cases & Commentaries
- Spotlight Case
- Web M&M
Laxmaiah Manchikanti, MD, and Joshua A. Hirsch, MD; September 2013
Hospitalized for pneumonia and asthma, a man with chronic pain was found to be using pain medications not prescribed to him. During his hospitalization, the pain service was consulted and changed his medications to better control the pain. Five days after discharge, the patient died, presumably from an unintentional overdose of his old and new prescriptions.
Perspectives on Safety > Interview
The Transformation of Patient Safety at the VA, September 2006
James P. Bagian, MD, is the Director of the Department of Veterans Affairs National Center for Patient Safety. Dr. Bagian began his career as a mechanical engineer, then became a physician, trained in surgery and anesthesia. A NASA Astronaut for 15 years, he flew on two space shuttle flights. In 2001, the American Medical Association awarded him the Nathan S. Davis Award for outstanding public service in the advancement of public health. We asked Dr. Bagian to speak with us about his experience transforming safety at in Veterans Affairs hospitals nationwide.
FDA Public Health Advisory. Silver Spring, MD: US Food and Drug Administration; December 21, 2007.
This Food and Drug Administration public health advisory alerts health care professionals, patients, and their caregivers to the possibility for overdoses of fentanyl in patients using fentanyl skin patches for pain control.
Wisc Med J. 2006:105;1-86.
This special issue includes articles on programs and initiatives to improve the safety of health care. It also includes proceedings from a 2006 Wisconsin conference on patient safety.
Bethesda, MD: National Council on Patient Information and Education; August 2007.
This report discusses poor medication adherence as a public health issue, describes contributing factors, and outlines a 10-step action plan to improve adherence.
Journal Article > Commentary
Gooden R, Syed SB, Rutter P, Hightower JD, Kelley E. Community Dev J. 2014;49:631-641.
This commentary provides information about an approach to augment patient safety through public health engagement. Implemented in partnership with six African countries to spread and sustain safe care practices, the initiative utilized a seven-component model to bring together community leaders and hospitals to drive improvement. A recent AHRQ WebM&M perspective covered lessons learned throughout implementation of the program.
Journal Article > Study
Shiffman S, Cotton H, Jessurun C, Rohay JM, Sembower MA. J Am Pharm Assoc (2003). 2016;56:495-503.
Poor health literacy is associated with the misunderstanding of medication labels, which can lead to adverse drug events. This study sought to assess how adding an acetaminophen icon to the labels of acetaminophen-containing medications affects consumers' ability to avoid unintentional overdose, which is known to cause liver damage. Investigators found that presence of the icon reduced the likelihood of medication errors by 53%, and they concluded that the icon may particularly benefit those with lower health literacy. A past WebM&M commentary discussed a case of liver injury caused by incorrect dosing of acetaminophen.
Journal Article > Review
Elmontsri M, Banarsee R, Majeed A. JRSM Open. 2018;9:2054270418786112.
Health care safety is a global concern. This review examined the literature on improvement experience from developed countries and identified common themes. The authors recommend a patient-centered, systems-oriented approach built on leadership, teamwork, transparency, and communication as key elements for effectively implementing improvement efforts in developing countries.