Narrow Results Clear All
Communication between Providers
- Sbar 1
- Communication between Providers
- Culture of Safety 1
- Education and Training 3
- Error Reporting and Analysis 4
- Human Factors Engineering 2
- Legal and Policy Approaches
- Logistical Approaches 1
- Quality Improvement Strategies 3
- Technologic Approaches 1
- Diagnostic Errors 2
- Discontinuities, Gaps, and Hand-Off Problems 4
- Identification Errors 4
- Medication Safety 1
- Surgical Complications 4
Search results for ""
Perspectives on Safety > Interview
The Patient's Role in Safety, March 2007
Sorrel King is the mother of Josie King, who died tragically in 2001 at age 18 months because of medical errors during a hospitalization at Johns Hopkins Hospital. She has subsequently become one of the nation’s foremost patient advocates for safety, forming an influential foundation (the Josie King Foundation) and partnering with Johns Hopkins to promote the field of patient safety around the world.
Landro L. Wall Street Journal (Eastern edition). June 28, 2006:D1. [reprinted on Post-gazette.com].
This article reports on communication interventions such as SBAR (Situation-Background-Assessment-Recommendation) that make patient hand-offs more reliable.
Breast Cancer Services in Trafford and North Manchester. An Investigation Into The Circumstances Surrounding A Serious Clinical Incident In Symptomatic Breast Services – The Baker Report.
Baker M. Manchester, England: NHS North West; February 2007.
This report shares findings from an investigation into individual and system failures that contributed to a radiologist misreading mammograms for a 2-year period.
Urbina I, Nixon R. New York Times. March 30, 2007;National Desk section:1.
This article reports on the inconsistent use of the Department of Defense electronic medical records system and how this has led to medical errors and delays in care for US veterans.
Learning from Bristol: The Report of the Public Inquiry into Children's Heart Surgery at the Bristol Royal Infirmary 1984–1995.
London, England: The Stationery Office; July 2001.
In June 1998, the Secretary for Health announced to Parliament the organization of a formal Inquiry into children's heart surgery at the Bristol Royal Infirmary between 1984 and 1995. Their objectives included understanding what happened in Bristol, assessing the quality of care and system failures that contributed to deaths, and generating lessons that could be learned for the entire National Health Service (NHS) in the United Kingdom. The inquiry was independent and not held as a legal proceeding, but provided a comprehensive investigation with interviews, expert panels, and a goal of driving improvement efforts. Section one of the report outlines pediatric cardiac surgical services in Bristol while section two focuses on recommendations to ensure high quality care across the NHS. Several publications resulted from the learnings of the Bristol inquiry, including a discussion of cultural entrapment and lessons for quality improvement.
Kowalczyk L. Boston Globe. April 21, 2007:B1.
This article reports on the results from Joint Commission site inspections of five Boston-area hospitals.
Smith S. Boston Globe. July 30, 2008;Metro section:1A.
This article reports on the incidence of wrong site surgeries in Massachusetts and describes complex factors that may contribute to such errors occurring in spinal surgery.
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.
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.
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.