Narrow Results Clear All
- WebM&M Cases 1
- Perspectives on Safety 4
- Commentary 11
- Study 4
- Audiovisual 33
- Book/Report 15
- Legislation/Regulation 7
- Newspaper/Magazine Article 214
- Special or Theme Issue 3
- Toolkit 1
- Web Resource 21
- Award 4
- Grant 2
- Meeting/Conference 2
- Press Release/Announcement 3
Communication between Providers
- Sbar 1
- Communication between Providers 10
- Culture of Safety 14
Education and Training
- Students 1
Error Reporting and Analysis
- Error Reporting 73
- Human Factors Engineering 18
Legal and Policy Approaches
- Regulation 52
- Logistical Approaches 6
- Policies and Operations 1
- Quality Improvement Strategies 46
- Teamwork 4
- Clinical Information Systems 13
- Transparency and Accountability 8
- Device-related Complications 14
- Diagnostic Errors 28
- Discontinuities, Gaps, and Hand-Off Problems 17
- Drug shortages 7
- Failure to rescue 1
- Fatigue and Sleep Deprivation 4
- Identification Errors 12
- Medical Complications 40
- Medication Errors/Preventable Adverse Drug Events 33
- MRI safety 1
- Nonsurgical Procedural Complications 5
- Overtreatment 1
- Psychological and Social Complications 11
- Surgical Complications 50
- Transfusion Complications 3
- Ambulatory Care 32
- General Hospitals 50
- Long-Term Care 8
- Outpatient Surgery 8
- Psychiatric Facilities 1
- Allied Health Services 1
- Internal Medicine 83
- Pediatrics 15
- Nursing 10
- Pharmacy 21
- Family Members and Caregivers 19
- Health Care Executives and Administrators 88
Health Care Providers
- Nurses 5
- Physicians 17
Non-Health Care Professionals
- Media 7
- Australia and New Zealand 3
- Europe 10
- Canada 8
Search results for ""
Landro L. Wall Street Journal. January 21, 2009:B7.
This newspaper article reports on efforts to increase physicians' use of electronic prescribing and describes benefits such as error reduction and cost savings.
Donaldson L. BBC News. Feb 26, 2009.
This article explores the importance of apology, its benefits, and some barriers to its expression in health care.
Golden, CO: HealthGrades, Inc.; April 2009.
This analysis of patient safety in Medicare patients from 2005–2007 concludes that while modest improvements have been made, patient safety incidents still account for nearly 100,000 preventable deaths and nearly $7 billion in excess costs yearly. The report also recognizes the best performing hospitals with a "Patient Safety Excellence Award"—hospitals scoring in the top 15% according to a ranking methodology developed by the authors. As with prior HealthGrades reports, the study uses the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSIs) to measure the incidence of patient safety problems and compare hospitals. The limitations of using PSIs as a performance measure have been discussed in a prior study and AHRQ WebM&M commentary, and it is important to note that this report did not undergo external peer review.
Kowalczyk L. Boston Globe. April 17, 2009;Metro:1.
This newspaper article discusses one hospital's decision to temporarily close its pediatric cardiac surgery program following errors that caused serious complications for two infants.
Berens MJ, Armstrong K. Seattle Times. November 16-18, 2008.
This three-part journalistic investigation highlights efforts in Washington State to track and minimize the spread of methicillin-resistant Staphylococcus aureus (MRSA) and to address organizational resistance to changes needed to mitigate the problem.
Jewell K, McGiffert L. Austin, TX: Consumers Union; 2009.
The 10 years since the release of the Institute of Medicine's To Err Is Human report have yielded some improvements in patient safety, but this Consumers Union report reminds clinicians and consumers alike that much work remains to be done. As the report notes, preventable safety problems such as medication errors and health care–associated infections still cause significant morbidity and mortality, despite the existence of effective preventive strategies. The report advocates for standardized measurement and public reporting of errors and calls for tighter accreditation standards for health care professionals.
Rein L. Washington Post. July 21, 2009:E1.
This news article reports on Washington, DC–area initiatives to track preventable patient injury and discusses strategies to hold hospitals accountable to reduce the number of avoidable incidents.
Seeking a safer surgery: some states crack down on doctors who perform unregulated outpatient procedures.
Landro L. Wall Street Journal. July 21, 2009:D1.
This article discusses growing legal oversight on outpatient surgery performed in physicians' offices and identifies ways in which patients can assess a facility before deciding to have a procedure there.
Journal Article > Commentary
Boothman RC, Blackwell AC, Campbell, Jr. DA, Commiskey E, Anderson S. J Health Life Sci Law. 2009;2:125-159.
This legal discussion shares one hospital system's approach to addressing error and apology in a proactive and sensitive way—that also makes smart business sense.
Audiovisual > Audiovisual Presentation
Kurtis B. New York Times. A&E Television Networks; 2008.
This 40-minute news feature interviews patients and others about clinical errors, inappropriate care, ineffective peer review, and systemic improvement in health care.
Goldhill D. The Atlantic. September 2009.
In the context of his father's death from a hospital-associated infection, the author discusses health system reform and quality of care in the United States.
Landro L. Wall Street Journal. August 25, 2009:D1.
This column shares the experience of hospitals and families whose involvement in open disclosure has resulted in improved care, reduced litigation costs, and patient partnerships.
Young A. The Atlanta Journal-Constitution; September 20, 2009:B1.
This newspaper article reports on numerous prescription mistakes in retail pharmacies in Georgia and offers tips for consumers to help prevent errors with their medications.
Zarembo A. Los Angeles Times. October 15, 2009:A1.
This news piece describes communication gaps following a radiation overdose incident thought to involve more than 200 patients at one hospital.
Westfall SS, Mascia K. People. October 5, 2009;72:155.
This story discusses an instance of mistakenly implanted embryos and the impact of the error on the two families involved.
Cohen E. Empowered Patient. CNN.com. November 13, 2009.
This news story describes an incident of patient misidentification and offers tips to help patients confirm their care during a hospitalization.
Kauffman M, Altimari D. The Hartford Courant. November 15, 2009;Final:A1.
This newspaper article reports that a Connecticut law intended to make hospital errors more transparent has had the opposite effect by making it easier for hospitals to limit publicly available information on adverse events.
Altman LK. New York Times. December 11, 2001;1:1.
This news piece reports on wrong-site and wrong-patient surgery and describes efforts to prevent surgical errors following a Joint Commission sentinel event alert on the topic.
Sack K. New York Times. February 11, 2010.
This newspaper article discusses the case of a nurse charged with felony harassment after reporting a safety concern about a particular physician to the state medical board.
Zarembo A. Los Angeles Times. April 6, 2010.
This newspaper article reports on device failures in the context of organizational and individual accountability for unreliable equipment, aborted surgery, and treatment delay.
Austin, TX: Texas Medical Institute for Technology and the Quaid Foundation; 2010.
This documentary reports on families affected by medical errors; it includes the story of a high-profile heparin overdose and how it transformed the family of actor Dennis Quaid into advocates for patient safety.
Quintero F. Orlando Sentinel. June 16, 2010;A1.
This newspaper article reports how one hospital system introduced advanced training programs to ensure safe use of surgical robots.
Stein L. St. Petersburg Times. June 21, 2010.
Reporting on wrong-site surgeries in Florida hospitals, this newspaper article describes how timeouts have changed the nature and frequency of surgical errors.
Allen M, Richards A. Las Vegas Sun. June 27, 2010.
This news series reports on an investigation that included hospital record review and interviews with stakeholders to explore the quality and safety of health care in Las Vegas.
Schulz K. Slate.com. June 28, 2010.
This discussion with the head of the National Center for Patient Safety reveals insights on reliability, reporting, and system improvement gleaned from his career in high-risk industries.
Smith ML, Wolfe WA. Star Tribune. July 22, 2010;News:1B.
This newspaper article reports on a lawsuit regarding a safety incident that led to injury and subsequent death of a patient.
Grant M. AARP The Magazine. September/October 2010;53:48-51,90-91.
Bernhard B, Kohler J. St. Louis Post-Dispatch. August 1, 2010:A1
In the context of system failures that contributed to the death of a patient, this newspaper article describes how never events are rarely publicized, even though hospital inspection reports are public records.
Harris G. New York Times. August 21, 2010:A1.
This article describes documented look-alike issues with medical equipment that have yet to be addressed by federal regulation.
Hughes J. BBC News. August 12, 2010.
This article reveals how the majority of hospitals have not acted on British National Health Services (NHS) safety alerts.
Chen PW. New York Times. August 19, 2010.
Landro L. Wall Street Journal. September 27, 2010.
Reporting how malpractice claims have exposed the frequency of diagnostic errors, this newspaper article discusses steps hospitals and insurance companies are taking to reduce such errors.
Vedder T. Problem Solvers. KOMO 4 News. October 1, 2010.
This news piece discusses medication errors that led to adverse events in a Seattle children's hospital.
Freudenheim M. New York Times. December 13, 2010:3B.
This article reports on a committee created by the Institute of Medicine to analyze the potential impact of electronic medical records (EMR) on costs and quality of care.
Bogdanich W, Rebelo K. New York Times. December 28, 2010;A1.
This article explores inaccuracy of dosage, lack of protocol adherence, and absence of transparency as trends that hinder learning from radiological adverse events.
Tarkan L. New York Times. January 25, 2011:D1.
This newspaper article reports on the aging of the physician population and its potential risks to patient safety.
Web Resource > Multi-use Website
This organization rates online health care report cards and provides tips for reporting quality concerns.
Valencia MJ. Boston Globe. March 10, 2011.
This newspaper article reports on a fatal medication error involving an anticoagulant overdose.
Allen M. Washington Monthly. March/April 2011.
This magazine article reports on medical errors in the United States health care system and discusses transparency as a tactic to improve patient safety.
Harasim P. Las Vegas Review-Journal. March 15, 2011:1A.
This newspaper article reports how a physician reused single-use equipment and put patients at risk for blood-borne diseases.
PBS News Hour. April 12, 2011.
Stremikis K, Schoen C, Fryer AK. 2011;6:1492.
This publication reports on consumers' views of health care in the United States, including their concerns about health care quality and direct experience with medical errors and iatrogenic conditions.
Legislation/Regulation > Congressional Testimony
Full Committee Hearing. US Senate Committee on Health, Education, Labor and Pensions (May 5, 2011) (testimony of Carolyn Clancy, MD; Timothy Charles; Philip Mehler, MD).
This testimony highlights insights from a policy leader, chief medical officer, and hospital leader on US government efforts to improve health care quality and safety.
Stein R. Washington Post. May 2, 2011:A10.
This newspaper article discusses the impact of drug shortages on patient safety.
Moss-Coane M, O'Connell K, Fishman N. Radio Times. April 28, 2011.
This radio program featured interviews with an infectious disease specialist and a patient who contracted a hospital-acquired infection, and discussed how patients and providers can reduce their occurrence.
Cohn M. Baltimore Sun. May 27, 2011:A1.
This newspaper article reports on plans to develop the Armstrong Institute for Patient Safety and Quality at Johns Hopkins. The institute is dedicated to improving patient safety and reducing medical errors.
Szabo L. USA Today. August 15, 2011.
This news article discusses how drug shortages affect patients, hospitals, and pharmacists, and explores reasons for the shortages.
Allen M. ProPublica. January 9, 2013.
This article reveals lessons a medical student learned about patient safety while dealing with errors that occurred during her mother's hospitalization.
Saltzman W. ABC/WPVI. February 5, 2013.
Chen PW. New York Times. February 14, 2013.
This newspaper article reports on a recent commentary discussing how hierarchy among physicians can influence the care they deliver.
Audiovisual > Audiovisual Presentation
Couric K. Katie. February 20, 2013.
This television program features patients and families discussing experiences with medical errors. The host interviews Dr. Peter Pronovost, who offers tips for patients to help prevent mistakes during hospitalization and surgery.
Eisler P. USA Today. March 8, 2013.
McFadden C. ABC News Nightline. March 6, 2013.
Brown T. New York Times. March 17, 2013:SR5.
Cohn J. The Atlantic. March 2013;311:59–67.
This magazine article reports how technology, such as IBM's Watson, can improve the efficiency and accuracy of health care decision making.
Tomsic M. WFAE Charlotte. National Public Radio. March 21–23, 2013.
This news series reports on the drug shortage problem, its impact on providers and patients, how it began, and concerns that wholesale companies are making it worse.
Howard B. AARP The Magazine. April/May 2013;56:46-50,52,71.
This magazine article details how several hospitals have taken a comprehensive approach to improving patient safety in their organizations. An interactive graphic displays many of the methods being used; an accompanying tool lists hospitals and their safety features.
Chen PW. New York Times. April 18, 2013.
Teegardin C. Atlanta Journal-Constitution. April 28, 2013.
Hartcollis A. New York Times. May 29, 2013:A18.
This newspaper article reports on efforts, such as remote video monitoring or distributing "red cards," to improve hand hygiene compliance in hospitals.
Natt TM Jr. The Pilot. August 9, 2013.
This news article reports how a hospital was placed on "immediate jeopardy" status and revised its policy for fire safety in the operating room after a patient was injured during a surgical fire.
Eisler P, Hansen B. USA Today. August 20, 2013.
This newspaper article reports on physicians with records of misconduct and how poor oversight for monitoring and discipline allows them to continue practicing medicine.
Allen M. ProPublica. September 19, 2013.
Consumer Reports on Health. November 2013;25:6-7.
Wise S, Sears T. CBS 6 WTVR. October 24, 2013.
This news piece reports that caregivers at schools in Virginia are often nurse aides, secretaries, and administrators with insufficient medical knowledge.
Jones R. WXYZ. November 13, 2013.
This news piece reports on risks associated with medication delivery in nursing homes and reveals several incidents that resulted in significant patient harm.
Burcham K. WSOC-TV. November 22, 2013.
This news piece reports on a missed diagnosis of meningitis and illustrates how premature closure can hinder safe care.
Harrow, Middlesex, UK: The Patients Association; 2013.
This publication provides patient and family accounts of incidents involving inadequate care or harm and highlights the need for improvements recommended in a National Health Services report.
Woodall A. Oakland Tribune. September 27, 2011.
This newspaper article reports how a medical error, which occurred during a nursing strike, resulted in a patient's death.
Institute of Medicine. Washington, DC: The National Academies Press; 2011. ISBN: 9780309218030.
This lecture features Kathleen Sebelius, Secretary of Health and Human Services (HHS), and a distinguished panel of guests discussing measures taken by HHS to drive innovation and progress in patient safety.
Levey NN. Los Angeles Times. October 4, 2011.
This newspaper article reports on improving US health care and profiles Dr. Donald Berwick, highlighting his commitment and contributions to patient safety and quality work.
Audiovisual > Audiovisual Presentation
Faye J. NBC-17 News. November 10, 2011.
This news segment discusses how drug shortages can affect providers, patients, and decisions about medication therapy.
Journal Article > Commentary
Davis Giardina T, Singh H. JAMA. 2011;306:2502-2503.
This commentary discusses a federal proposal to provide patients with direct access to laboratory test results as a tactic to reduce errors.
Legislation/Regulation > Congressional Testimony
Testimony before the Committee on Health, Education, Labor, and Pensions, US Senate. US Government Accountability Office. GAO-12-315T (December 15, 2011) (testimony of Marcia Crosse, PhD).
Simons A. Star Tribune. January 4, 2012:1A.
This newspaper article describes how a delay in diagnosis resulted in minimal chance of survival and discusses legal issues surrounding the case.
Journal Article > Study
Hinchcliff R, Westbrook J, Greenfield D, Baysari M, Moldovan M, Braithwaite J. Int J Qual Health Care. 2012;24:1-8.
Vaida B. The Washingtonian. January 27, 2012.
This magazine article discusses patient safety improvement efforts as well as challenges hindering more widespread error reduction.
Consumer Reports. January 26, 2012.
Consumer Reports analyzed publicly reported infection rates for 92 pediatric intensive care units (ICUs) and found that hospital-acquired infections were 20% higher in pediatric ICUs than in adult ICUs.
Rau J. Washington Post. February 12, 2012:A03.
This news article describes problems with analyzing data from a 2011 report on hospital-acquired conditions to accurately measure a hospital's overall quality of care.
Snyderman N. NBC News. February 22, 2012.
This news video reports how inadequate sterilization of surgical instruments can affect patient safety.
Journal Article > Study
High-profile investigations into hospital safety problems in England did not prompt patients to switch providers.
Laverty AA, Smith PC, Pape UJ, Mears A, Wachter RM, Millett C. Health Aff (Millwood). 2012;31:593-601.
While medical errors continue to affect patients on a daily basis, most organizations fear high-profile cases that land on front pages of newspapers or lead to extensive regulatory intervention. This study evaluated the role of England's Care Quality Commission in their own regulatory investigation of major issues occurring in three hospitals. The investigations led to considerable media attention, but whether this influenced patient behavior was unknown. The authors found that the investigations had zero impact on utilization at two of the hospitals. The third experienced a decrease in inpatient admissions and new patient visits, but the effect dissipated 6 months following the public report. In an era of greater transparency and increased attention on patient safety, these findings suggest that patients' decision-making is perhaps less influenced than expected by such events. Two past AHRQ WebM&M perspectives discussed organizational change in the face of highly public errors at Duke and the Dana Farber Cancer Institute.
Greider K. AARP Bulletin. March 2012;53:10,12,14.
Willams B. The Record. March 10, 2012.
Exploring how drug shortages affect patients, this news piece describes one cancer patient's efforts to acquire the chemotherapeutic agent that is prolonging his life.
Sanders L. New York Times Magazine. March 18, 2012.
This interactive magazine feature takes readers through the decision-making process in a case involving diagnostic error.
Gupta S. New York, NY: Grand Central Publishing; 2012. ISBN: 9780446583855.
To illustrate how physicians learn from mistakes, this novel (written by CNN medical correspondent Dr. Sanjay Gupta) explores the impact of a medical error on surgeons at one hospital.
Cohen E. CNN. April 9, 2012.
This news article reports on errors that contributed to the death of a live organ donor and describes regulations to protect organ donors' safety.
LaGrone K. WPTV.com. April 30, 2012.
This news piece discusses pharmacy medication dispensing errors and describes how patients can help prevent them.
Landro L. Wall Street Journal. June 5, 2012;D1.
This newspaper article describes how one hospital reduced hospital-acquired infection rates.
Gawande A. The New Yorker: News Desk. June 4, 2012.
This piece, originally delivered as a commencement speech, discusses the importance of recognizing failure and understanding how to plan for and respond to it in order to improve outcomes.
Dwyer J. New York Times. July 11, 2012:A15.
This newspaper article reports on gaps in communication and a missed sepsis diagnosis that led to a patient's death.
Gupta S. CNN. July 23, 2012.
This news video reports on how drug shortages affect patients and describes US Food and Drug Administration (FDA) efforts to address the issue.
Miller R. News-Times. July 25, 2012.
This newspaper article details the complications and errors a patient experienced following a routine surgery.
Hartocollis A. New York Times. July 28, 2012.
This newspaper article reports on the missteps that contributed to the death of a young woman after she was hospitalized in an incident reminiscent of Libby Zion.
Terhune C. Los Angeles Times. August 3, 2012:B1.
This newspaper article reports on an incident during which dozens of hospitals lost access to electronic medical records (EMRs) and discusses risks associated with EMR systems.
Eisler P. USA Today. August 16, 2012.
This newspaper article reports on how clinicians, hospitals, and health care systems can reduce incidence of hospital-acquired Clostridium difficile infections.
Web Resource > Multi-use Website
Tanya and Phil Barnett.
This Web site includes a video chronicling how an undiagnosed heart condition led to a teenager's death and offers tips for patients to prevent medical errors.
Kolata G. New York Times. August 22, 2012.
Despite strict infection controls placed around a patient carrying a deadly antibiotic-resistant bacteria, 17 other patients also became infected and 6 died. This newspaper article details the approach used to track the chain of transmission.
Messina I. Toledo Blade. August 24, 2012.
This newspaper article discusses an incident in which a transplant organ was mistakenly discarded.
Sternberg S. US News & World Report. August 28, 2012.
This magazine article discusses insights from experts and patients on how to prevent errors in hospitals in the United States.
Grady D, Pollack A, Tavernise S. New York Times. October 6, 2012.
This newspaper article discusses how the drug shortage and use of compounded drugs contributed to an outbreak of fungal meningitis in the United States. The outbreak has already led to more than a dozen deaths.