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- Communication Improvement 16
- Culture of Safety 3
- Education and Training 13
- Error Reporting and Analysis 16
- Human Factors Engineering 8
- Legal and Policy Approaches 27
- Logistical Approaches 3
- Policies and Operations 2
- Quality Improvement Strategies 15
- Technologic Approaches 5
- Transparency and Accountability 3
- Device-related Complications 8
- Diagnostic Errors 24
- Discontinuities, Gaps, and Hand-Off Problems 5
- Failure to rescue 1
- Interruptions and distractions 1
- Medical Complications 18
- Medication Safety 10
- Nonsurgical Procedural Complications 2
- Psychological and Social Complications 2
- Surgical Complications 11
- Allied Health Services 1
- Internal Medicine
- Nursing 4
- Palliative Care 1
- Pharmacy 1
- Europe 5
- Canada 2
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Cases & Commentaries
- Spotlight Case
- Web M&M
Elizabeth B. Lamont, MD, MS; September 2004
Following hernia repair surgery, an elderly woman is incidentally found to have a mass in her neck. Expecting the worst, the treating physician recommends palliative care and withdrawal of mechanical ventilation, before biopsy results are in.
Cases & Commentaries
- Spotlight Case
- Web M&M
Brittany McGalliard, PharmD; Rita Shane, PharmD; and Sonja Rosen, MD; September 2016
An elderly woman with multiple medical conditions experienced new onset dizziness and lightheadedness. A home visit revealed numerous problems with her medications, with discontinued medications remaining in her pillbox and a new prescription that was missing. In addition, on some days she was taking up to five blood pressure pills, when she was supposed to be taking only two.
Zimmerman R. Wall Street Journal. February 6, 2007:A1.
This article reports on a mother's campaign to educate parents about kernicterus and to make bilirubin tests standard for all newborns.
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.
Sanders L. New York Times Magazine. April 22, 2007:28, 30.
A physician shares her experience with failing to diagnose a patient's prostate problems.
Pear R. New York Times. August 19, 2007.
This article reports on a new Centers for Medicare and Medicaid Services (CMS) rule mandating that Medicare will no longer pay for treating certain preventable errors starting in 2008, including some hospital-acquired infections, decubitus ulcers, and retained foreign bodies. The policy is generating considerable discussion in patient safety circles, with some expressing concerns regarding the economic impact on hospitals and the increased efforts it is likely to create for hospitals to document certain patient problems present at the time of admission.
Allen M. Las Vegas Sun. March 2, 2008.
This article and accompanying video describe how investigators determined the root causes and source of a hepatitis outbreak in Nevada—one clinic's unsafe injection practices.
Information for healthcare professionals: risk of transmission of blood-borne pathogens from shared use of insulin pens.
FDA Alert [US Food and Drug Administration Web site]. March 19, 2009.
This announcement alerts clinicians and patients that insulin pens and insulin cartridges are never to be used on more than one patient.
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.
Bogdanich W. New York Times. June 20, 2009;National Desk:1.
Flawed safety standards, including a lack of peer review and oversight, led to a series of errors in a cancer unit at a Philadelphia Veterans Affairs hospital.
May H. Salt Lake Tribune. June 26, 2009.
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.
Haiken M. Caring.com. August 17, 2009.
To help consumers use medications safely, this article describes 10 common medication mistakes and provides tips on how effective communication and clarification can prevent them.
Chen PW. New York Times. September 17, 2009.
The author uses personal experience to explain how sterile technique is strict in the operating room. The column highlights the Joint Commission effort to improve hand hygiene compliance in the health care system as a whole.
Bogdanich W. New York Times. January 24, 2010:A1.
First in a series on medical radiation, this news feature and accompanying video investigate patient deaths and injuries following mistakes related to radiation treatment. The journalists discuss the number of radiation therapy errors in New York and reveal that state law does not require public reporting of such mistakes.
Kowalczyk L. Boston Globe. February 21, 2010.
This news account discusses a patient death after a heart monitor alarm was inadvertently turned off. Hospital and device safety experts weigh in on strategies to prevent these types of errors.
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.
Kowalczyk L. Boston Globe. September 21, 2011.
Reporting on a patient death involving alarm fatigue, this newspaper article describes how one hospital adopted aggressive measures to prevent similar incidents.
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.
Shelton DL. Chicago Tribune. October 7, 2011.
Reporting on a fatal medical error, this article describes how the family became involved with patient safety, serving on an advisory council at the hospital where it occurred.