Narrow Results Clear All
- Communication Improvement 9
- Education and Training 4
- Error Reporting and Analysis 3
- Human Factors Engineering 4
- Legal and Policy Approaches 4
- Logistical Approaches 1
- Quality Improvement Strategies 4
- Clinical Information Systems 10
- Device-related Complications 2
- Diagnostic Errors 8
- Discontinuities, Gaps, and Hand-Off Problems 3
- Identification Errors 2
- Interruptions and distractions 1
- Medical Complications 2
- Medication Safety 9
- Psychological and Social Complications 1
- Surgical Complications 5
- Internal Medicine 5
- Surgery 5
- Nursing 1
- Pharmacy 2
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Cases & Commentaries
- Web M&M
Tejal K. Gandhi, MD, MPH; October 2003
Switched urine specimens lead to a patient receiving the wrong answer about her pregnancy test.
Paterson R. Auckland, New Zealand: Office of the Health and Disability Commissioner; April 24, 2007.
This report analyzes an incident of medication error that led to a patient's death, discusses the subsequent actions taken by the health board, and calls for a coordinated approach to medication reconciliation in New Zealand.
Donaghue E. USA Today. September 5, 2007.
This article discusses how diagnostic decision-support systems can assist physicians in correctly diagnosing patients.
Lin R-G II, Watanabe T. Los Angeles Times. November 22, 2007;A1.
This article reports on a non-fatal medication error that involved several neonates (including the newborn twins of actor Dennis Quaid) receiving a concentration of heparin 1000 times higher than intended. The discussion includes current hospital efforts to prevent medication errors and the growing interest in use of bar coding technology. A similar error captured headlines in 2006 when it caused the deaths of three infants.
The Oprah Winfrey Show. March 10, 2009.
This feature spotlights Dennis Quaid's experience with medical errors and offers tips for patients on protecting their health.
May H. Salt Lake Tribune. June 26, 2009.
Tragic medication errors result in accidental abortions and premature birth—safety advocates say drug mistakes are still too frequent, despite advances.
Patel A. ABCnews.com. August 21, 2009.
This news piece describes two look alike/sound alike medication errors in which pregnant women were given the wrong drug.
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.
Aleccia J. MSNBC.com; May 28, 2010.
This news piece details errors involving medication name confusion and presents tips for consumers to avoid such mistakes.
Eban K. Self Magazine. November 2011.
This magazine article reports on cases in which outsourcing the interpretation of radiology tests contributed to patient harm.
Gold J. Kaiser Health News and National Public Radio. March 26, 2012.
This news article highlights the risks and benefits of using mobile technology in health care. An AHRQ WebM&M commentary discusses the error mentioned, in which a text message interrupted a medication order.
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.
Carr N. The Atlantic. November 2013.
Increasingly, computerized systems are performing more complex tasks in high-risk industries like aviation and medical care. This magazine article reports how overreliance on automation can diminish human performance, decision-making, and situational awareness—and thereby lead to errors.
Grant M. AARP The Magazine. September/October 2010;53:48-51,90-91.
Landro L. Wall Street Journal. May 10, 2011:D3.
This newspaper article reports on efforts to reduce errors in emergency medicine, including improving physician–nurse communication, adopting timeouts before discharge, and using trigger systems.
Graham J, Dizikes C. Chicago Tribune. June 27, 2011.
This newspaper article reports on an order entry error that resulted in a 60-fold overdose and raised concerns about the safety of electronic medication data systems.
Hamill SD. Pittsburgh Post-Gazette. July 10, 2011:A6.
This newspaper article reports how a missed test result alert led to a disease-free transplant patient being infected with hepatitis.
Eisler P. USA Today. March 8, 2013.
Landro L. Wall Street Journal. June 9, 2014.
As they become more prevalent, electronic medical records (EMRs) are being used to improve safety in increasingly creative ways. This newspaper article reports on efforts to engage patients in reviewing their medication lists by providing them with access to EMR systems in order to detect and correct discrepancies in data.
Sathya C. CNN. August 22, 2014
This news article reports on the development a surgical black box, which includes using cameras and microphones to record procedures, as a way to track weaknesses in techniques and processes while providing real-time feedback to surgeons and enabling timely intervention to reduce complications in surgery.