Narrow Results Clear All
- Study 1
- Slideset 1
- Legislation/Regulation 3
- Newspaper/Magazine Article
- Special or Theme Issue 11
- Toolkit 1
- Web Resource 25
- Award 4
Communication between Providers
- Sbar 2
- Communication between Providers 93
- Culture of Safety 95
Education and Training
- Students 3
Error Reporting and Analysis
- Error Reporting 92
Human Factors Engineering
- Checklists 23
Legal and Policy Approaches
- Regulation 24
- Logistical Approaches 39
- Policies and Operations 6
Quality Improvement Strategies
- Benchmarking 12
- Specialization of Care 34
- Teamwork 36
- Clinical Information Systems 65
- Transparency and Accountability 11
- Alert fatigue 1
- Device-related Complications 38
- Diagnostic Errors 28
- Discontinuities, Gaps, and Hand-Off Problems 58
- Drug shortages 7
- Failure to rescue 3
- Fatigue and Sleep Deprivation 10
- Identification Errors 26
- Interruptions and distractions 8
- Medical Complications 48
- Medication Errors/Preventable Adverse Drug Events 158
- MRI safety 2
- Nonsurgical Procedural Complications 12
- Psychological and Social Complications 33
- Second victims 3
- Surgical Complications 48
- Transfusion Complications 1
- Ambulatory Care 40
- General Hospitals 91
- Long-Term Care 11
- Outpatient Surgery 5
- Patient Transport 4
- Psychiatric Facilities 3
- Allied Health Services 3
- Internal Medicine 156
- Obstetrics 12
- Pediatrics 17
- Nursing 55
- Palliative Care 1
- Pharmacy 86
- Family Members and Caregivers 17
- Health Care Executives and Administrators
Health Care Providers
- Nurses 80
- Pharmacists 36
- Physicians 89
Non-Health Care Professionals
- Educators 23
- Engineers 30
- Media 6
- Patients 129
- Asia 1
- Europe 29
- Canada 7
- United States of America 589
Search results for "Newspaper/Magazine Article"
- Newspaper/Magazine Article
- Health Care Executives and Administrators
ISMP Medication Safety Alert! Acute Care Edition. June 6, 2019;24.
Gabler E. New York Times. May 31, 2019.
Pediatric cardiac surgery is highly technical and risky. This newspaper article reports on a poorly performing pediatric cardiac surgery program, concerns raised by staff, and insufficient response from organizational leadership. Lack of data transparency, insufficient resources, and limited program capabilities to support a complex program contributed to poor outcomes for pediatric patients.
Hilton K, Anderson A. Harv Bus Rev. May 20, 2019.
This commentary describes how one health system worked to combat resistance to change associated with implementation of a checklist initiative. The success of the program was built on empowering team members to drive the process, clinician motivation to provide safe care, and engaging leadership. A PSNet interview with Lucian Leape discussed surgical safety checklists.
Ross C. STAT. May 13, 2019.
Nuisance alarms, interruptions, and insufficient staff availability can hinder effective monitoring and response to acute patient deterioration. This news article reports on how hospital logistics centers are working toward utilizing artificial intelligence to improve clinician response to alarms by proactively identifying hospitalized patients at the highest risk for heart failure to trigger emergency response teams when their condition rapidly declines.
CDC Vital Signs. May 7, 2019.
Maternal morbidity and mortality is a worldwide patient safety problem. This analysis describes the prevalence of pregnancy-related death and areas of concern during pregnancy, at delivery, and up to a year postpartum. It reports that 60% of these deaths are preventable and provides suggestions for families, clinicians, and systems to reduce risks.
Palmer J. Patient Saf Qual Healthc. May/June 2019.
Organizations must learn from adverse events to prevent similar incidents. Reporting on lessons to be learned from the cascade of failures connected with the preventable death of a patient during an acute asthma attack at the door of a hospital emergency department, this magazine article outlines the importance of effective signage, appropriate security staff placement, and acceptance of the responsibility for failure.
Jewett C. Kaiser Health News. May 3, 2019.
Transparency has been heralded as a cornerstone to improvement in health care. This news article reports on a government alternative summary reporting program that allowed medical device makers to conceal safety events and malfunction reports associated with medical devices. A new program that expands access to information about device-related failures will be put in place.
ISMP Medication Safety Alert! Acute Care Edition. April 25, 2019.
Newborns assigned temporary names are at increased risk for patient misidentification and wrong-patient errors. This newsletter article reports on the role of electronic health records in newborn misidentification and the unintended consequences associated with a Joint Commission set of recommendations to reduce risk.
Cheney C. HealthLeaders Media. April 17, 2019.
This news article describes how a 19-hospital health system successfully applied high reliability principles to emphasize a zero-tolerance focus on patient harm. The coordinated effort across the system achieved a drop in readmissions and physician burnout. Tactics used to improve reliability include huddles, purposeful redundancy, and leadership engagement.
Quick Safety. April 15, 2019;(48):1-3.
Fatigue, emotional stress, and illness can affect decision-making and lead to misuse of medications. This newsletter article describes the patient safety impacts of drug diversion among health care workers and notes the importance of a culture of constructive reporting to uncover and address this unsafe behavior.
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.
Erich J. EMS World. April 2019;48:26-31.
Air transport service combines risks associated with both aviation and prehospital trauma care. This article discusses the role of human factors in this fast-paced care environment. The author encourages efforts to reduce risks through policy change, purchasing the latest safety equipment, and empowering staff to decline calls when conditions are unsafe.
Field C, Finley E, Deutsch ES. PA-PSRS Pa Patient Saf Advis. 2019;16(1).
Schulte F, Fry E. Kaiser Health News, Fortune Magazine. March 18, 2019.
Despite years of investment and government support, electronic health records (EHR) continue to face challenges as a patient safety strategy. This news article outlines the unintended consequences of EHR implementation, including patient harm linked to software glitches and user errors, fraudulent behavior (upcoding), interoperability problems, clinician burnout due to poorly designed digital health records, and lack of industry transparency.
Rau J. Kaiser Health News. March 1, 2019.
Financial incentives may encourage adoption of practice improvements that enhance safety. This news article reports on the increase in United States hospitals that have had Medicare payments withheld due to high rates of hospital-acquired conditions. The article is accompanied by a state-level tally of individual hospitals penalized.
ISMP Medication Safety Alert! Acute Care Edition. February 28, 2019;24.
Medication warnings inform providers and patients about risks associated with medication use. As with other safety strategies, applying a systems approach to medication warnings can help redirect actions and prevent patient harm. This article describes design, content, and language characteristics of successful medication safety warnings. In addition, specific design and user-centered considerations are included to improve the effectiveness of electronic alerting.
Another round of the blame game: a paralyzing criminal indictment that recklessly "overrides" just culture.
ISMP Medication Safety Alert! Acute Care Edition. February 14, 2019;24.
Span P. New York Times. February 1, 2019.
Cognitive and functional decline can occur as individuals age. Concerns have been raised regarding the need to assess skills of aging physicians. This newspaper article reports on the implementation of mandatory evaluation programs to assess competencies of older surgeons and the profession's response to them.
Janik LS, Vender JS Grissinger M, Litman RS. APSF Newsletter. February 2019;33:72-75.
This pair of commentaries reviews the use of color-coded medications as an anesthesia safety strategy. The first article argues for implementing standard color sets to delineate drug class and use to improve medication safety. The dissenting article suggests that color-coded medications may decrease the chance of clinicians reading syringe labels carefully due to overreliance on color representation as a shortcut for reading the label.
Hixenbaugh M, Ornstein C. Houston Chronicle and Propublica.
This news investigation chronicles a series of incidents in a transplant program that resulted in patient harm. The systemic nature of the problems such as insufficient whistleblower protection, accountability, and follow-up on patient concerns culminated in a change of hospital leadership. A previous PSNet interview with Charles Ornstein discussed the role of media in raising awareness of patient safety issues.