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- Perspectives on Safety 2
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- Newspaper/Magazine Article 29
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- Error Reporting and Analysis 13
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- Medication Errors/Preventable Adverse Drug Events 33
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Search results for ""
Perspectives on Safety > Perspective
Organizational Change in the Face of Highly Public Errors—I. The Dana-Farber Cancer Institute Experience
with commentary by James B. Conway; Saul N. Weingart, MD, PhD, Errors in the Media and Organizational Change, May 2005
A decade ago, two tragic medical errors rocked one of the world’s great cancer hospitals, Dana-Farber Cancer Institute (DFCI) in Boston, to its core. The errors led to considerable soul searching and, ultimately, a major change in institutional practices a...
Perspectives on Safety > Perspective
with commentary by Rosemary Gibson, MSc, The Patient's Role in Safety, March 2007
Patients have three roles in improving patient safety: helping to ensure their own safety, working with health care organizations to improve safety at the organization and unit level, and advocating as citizens for public reporting and accountability of hospital and health system performance. The following case illustrates how patients can help ensure their own safety.
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.
Journal Article > Study
Stebbing C, Kaushal R, Bates DW. Pediatrics. 2006;117:1907-1914.
This study analyzed newspaper coverage of pediatric medication errors and adverse drug events in five countries to demonstrate increased interest in the topic over the past decade. Investigators examined the number of articles and the types of events covered and assessed the overall themes presented and framed by the media. The majority of articles published covered patient incidents followed by policy and then research in decreasing order of frequency. Despite the occasional occurrence of sensational reporting on errors, more than 70% of articles that were deemed to be negatively associated with patient safety were covered in a neutral manner.
Evanston, IL: Office of the Governor; July 13, 2006.
This news release announces the governor's plans to improve patient safety in Illinois, including the use of e-prescribing by all providers and a Division of Patient Safety within the state public health department.
Journal Article > Commentary
Levien TL. Hosp Pharm. 2006;41:697-709.
The author discusses the potential for medication errors with drugs using international brand names and provides tables of both identical and similar brand names that contain different active ingredients.
Wahlberg D, Treleven E. Wisconsin State Journal. November 3, 2006:A1.
This article reports on criminal charges brought against a nurse after she committed a medication error.
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.
Morris S. Guardian. February 13, 2007.
This story reports on an investigation into the death of an infant after heart surgery.
Award > Award Recipient
These annual awards recognize states and individual physicians for their use of e-prescribing technology.
Wolfe W. Minneapolis Star Tribune. February 28, 2007.
This article reports on three patient deaths due to errors at a state-owned nursing home for veterans.
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.
Talaga T, Cribb R. Toronto Star. March 19, 2007.
This article discusses disclosure of medical errors and shares stories from several Canadian hospitals on their policies for disclosing adverse events.
Kowalczyk L. Boston Globe. April 21, 2007:B1.
This article reports on the results from Joint Commission site inspections of five Boston-area hospitals.
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.
Tools/Toolkit > Fact Sheet/FAQs
FDA Consumer Health Information. Rockville, MD: US Food and Drug Administration; February 20, 2009.
This fact sheet discusses the role of the Food and Drug Administration (FDA) in reducing medication errors and describes examples of such errors for consumers.
Rusk K. Assignment 7. ABC7news.com. May 26, 2008.
In the context of statewide efforts to prevent medication errors, increase reporting, and share best practices, this news video addresses how hospitals are employing both low- and high-tech solutions to improve patient safety. The story also covers barcoding, the Five Rights, transparency, and efforts to get safety information into patients' hands.
Parents sue over babies' heparin overdoses: infants were given too much heparin at Methodist Hospital.
Higgins W. Indianapolis Star. September 13, 2008;News section:A1
Families whose infants died from or were harmed by heparin overdoses are suing the drug manufacturer and the hospital.
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.
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.
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.
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.
Grant M. AARP The Magazine. September/October 2010;53:48-51,90-91.
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.
Valencia MJ. Boston Globe. March 10, 2011.
This newspaper article reports on a fatal medication error involving an anticoagulant overdose.
Stein R. Washington Post. May 2, 2011:A10.
This newspaper article discusses the impact of drug shortages on patient safety.
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.
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.
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.
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.
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.
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.
LaGrone K. WPTV.com. April 30, 2012.
This news piece discusses pharmacy medication dispensing errors and describes how patients can help prevent them.
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.
Kane J. PBS NewsHour. October 23, 2012.
This video reveals how checklists can help patients and their families ensure safety during hospital care.
Glass I, Cole S. This American Life. WBEZ Chicago. September 20, 2013.
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.
Pierrotti A. USA Today. August 18, 2014.
Jaffe I, Renincasa R. Morning Edition. National Public Radio. December 8–9, 2014.
Overprescribing of medications is a common problem in nursing homes. This two-part radio segment reports on the inappropriate use of antipsychotic medications as a chemical restraint for patients with dementia. The first part introduces the issue and includes insights from families that have experienced harm due to the practice. The second segment discusses programs that the Centers for Medicare and Medicaid Services has put in place to address the problem through a more patient-centered approach to care and suggests strengthening penalties against organizations that overuse antipsychotics.
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.
Ornstein C. Washington Post. July 12, 2015.
Anticoagulants are considered high-alert medications that if used ineffectively can result in patient harm. Reporting on an anticoagulant commonly used in nursing homes and patient harm linked to this medication, this newspaper article relates reasons doctors are reluctant to prescribe new drugs to older patients and challenges to monitoring and preventing such adverse drug events.
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.
Mohr H, Weiss M. Associated Press. November 27, 2018.
Gordon M. Health Shots. National Public Radio. April 10, 2019.
Punitive responses to medical errors persist despite continued efforts to reduce them. This news article reports on an incident involving the mistaken use of a neuromuscular blocking agent that resulted in the death of a patient, the prosecution of the nurse who made the error, and systemic and human factors that contribute to similar events.
Dickson EJ. Rolling Stone. March 9, 2019.
Unintended consequences of restrictions enacted to combat the opioid crisis are a concern for patients and prescribers. This magazine article reports on an effort to raise awareness of the potential for patient harm due to lack of legitimate access to opioids for chronic pain as a result of the 2016 CDC opioid prescribing guidelines.
Web Resource > Multi-use Website
8230 Old Courthouse Road, Suite 420, Tysons Corner, VA.
A comprehensive systems-focused approach must be employed in the hospital and at home to ensure reliable medication use. This institute supports multistakeholder activities to enhance policy and education throughout health care to optimize and improve medication practices of caregivers, families, pharmacists, and clinicians.