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- Communication Improvement 3
- Education and Training 3
- Error Reporting and Analysis 6
- Legal and Policy Approaches
- Logistical Approaches 1
- Quality Improvement Strategies 2
- Technologic Approaches 3
- Diagnostic Errors 7
- Discontinuities, Gaps, and Hand-Off Problems 3
- Fatigue and Sleep Deprivation 1
- Identification Errors 1
- Medical Complications 4
- Medication Errors/Preventable Adverse Drug Events 12
- Psychological and Social Complications 1
- Surgical Complications 3
- Surgery 2
- Nursing 2
- Pharmacy 9
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Journal Article > Commentary
Medication errors in family practice, in hospitals and after discharge from the hospital: an ethical analysis.
Clark PA. J Law Med Ethics. 2004;32:349-357.
In this article, the author urges the medical community to universally apply the systems approach to safety toward the reduction of medical errors. The author calls for health care to take medication errors more seriously and for patients to help drive improvement.
Tools/Toolkit > Multi-use Website
Institute for Healthcare Improvement.
This website provides resources for promoting patient safety during Patient Safety Awareness Week. The 2019 observance will be held March 10–16 and will focus on improving safety in the ambulatory setting. A free webcast on March 13, 2019 between 2:00–3:00 PM (Eastern) will discuss outpatient safety improvement tactics, with Dr. Tejal Gandhi, Dr. Jeff Brady, and Lisa Shilling as featured speakers.
Bailey B, Sevrens Lyons J. The Mercury News. November 27, 2005.
This article reports on several errors that occurred at hospitals in California and discusses the state's regulatory system.
St. Paul, MN: Minnesota Department of Health; March 2019.
The National Quality Forum has defined 29 never events—patient safety problems that should never occur, such as wrong-site surgery and patient falls. Since 2003, Minnesota hospitals have been required to report such incidents. The 2018 report summarizes information about 384 adverse events that were reported and found pressure ulcers and invasive procedure events increased, while fall-related deaths decreased. Reports from previous years are also available.
Carter M. Seattle Times. March 9, 2007:A1.
This article investigates and reports on the prevalence of medical errors in a county jail system in Washington.
Fargen J. Boston Herald. April 22, 2007.
This article reports on a decrease in consumer complaints following improvements made by community pharmacies in Massachusetts.
Dworkin A. The Oregonian. June 20, 2007:A01.
This article reports on dispensing errors made by Oregon pharmacists and the fines imposed as penalty for those errors.
McCoy K, Brady E. USA Today. February 11, 2008:A1.
This series of investigative articles uncovers the factors involved in pharmacy errors, relates stories of patients harmed by such errors, and includes steps that consumers can take to minimize their risk.
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.
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.
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.
LaGrone K. WPTV.com. April 30, 2012.
This news piece discusses pharmacy medication dispensing errors and describes how patients can help prevent them.
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.
Cohen E. CNN. October 15, 2012.
This news piece reports on a patient who may have been misdiagnosed with a stroke after receiving a contaminated steroid injection.
Ackerman T. Houston Chronicle. November 23, 2012.
This newspaper article describes challenges that may precipitate underdiagnosis or misdiagnosis of Alzheimer disease and conditions with similar presenting symptoms.
Sanghavi D. Boston Globe Magazine. January 27, 2013.
McFadden C. ABC News Nightline. March 6, 2013.
Glass I, Cole S. This American Life. WBEZ Chicago. September 20, 2013.
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.
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.
Saltzman W. ABC/WPVI. February 5, 2013.
Jain M. Washington Post. May 27, 2013.
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.
Consumer Reports on Health. November 2013;25:6-7.
Rabin RC, Kaiser Health News. Washington Post. March 31, 2014.
This newspaper article reports on factors contributing to physician burnout and describes obstacles to resolving it. Burnout in the primary care setting was often related to business aspects such as insurance payments, managing staff, and increased oversight. Physician happiness was found to be tied to patient satisfaction, and electronic medical record use was perceived to impede meaningful interaction.
Boodman SG, Kaiser Health News. Washington Post. May 19, 2014.
Suares W. FOX 25 KOKH-TV. July 30, 2014.
This video news segment reports how incorrect medications can be dispensed from pharmacies, notes a lack of regulation mandating that pharmacy errors are reported, and offers tips for patients to reduce risks.
FDA Safety Communication. Silver Spring, MD: US Food and Drug Administration; February 25, 2015.
The practice of using multi-dose insulin pens, meant for single patient use only, among multiple patients has been linked to health care–associated infections. This announcement outlines federal labeling requirements to raise awareness of the risks associated with this practice to prevent misuse of the devices.
Offri D. New York Times. October 8, 2015.
This news article offers insights from a physician about the complexities around establishing a diagnosis in frontline practice and the recent IOM report recommendation to improve reimbursement systems as a way to encourage physicians to spend more time on the cognitive component of forming a diagnosis rather than simply ordering imaging tests.
Rau J. Washington Post. April 29, 2016.
Transitions in care between inpatient and outpatient settings are an increasing concern for patient safety. Reporting on a fatal medication error that was missed by a patient's pharmacist and home health nurses, this newspaper article discusses various risks associated with hospital-to-home transitions such as insufficient case management and communication.
Landro L. Wall Street Journal. May 9, 2016.
Closed claims have been considered a source for adverse event data for years, and recently such data has been utilized to inform safety improvement work. This newspaper article reviews several organizational efforts that use claims data to determine factors that contribute to failure and strategies to address them, including process redesign and enhanced patient education.
Frakt A. New York Times. July 11, 2016.
Patients are increasingly using online symptom checkers for medical information and health care recommendations. This newspaper article reports on various health information applications that provide triage advice to patients and points out that physicians have significantly lower rates of diagnostic errors.