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- Patient Safety Primers 1
- WebM&M Cases 1
- Perspectives on Safety 6
- Commentary 28
- Review 5
- Study 58
- Slideset 1
- Book/Report 20
- Legislation/Regulation 2
- Newspaper/Magazine Article 39
- Special or Theme Issue 3
- Toolkit 4
- Web Resource 15
- Award 2
- Bibliography 1
- Meeting/Conference 4
- Press Release/Announcement 1
- Communication Improvement 101
- Culture of Safety 15
Education and Training
- Students 2
Error Reporting and Analysis
- Error Reporting 52
- Human Factors Engineering 11
- Legal and Policy Approaches 22
- Logistical Approaches 3
- Policies and Operations 2
- Quality Improvement Strategies 34
- Research Directions 1
- Specialization of Care 13
- Teamwork 2
- Technologic Approaches 9
- Transparency and Accountability 10
- Alert fatigue 1
- Device-related Complications 3
- Diagnostic Errors 8
- Discontinuities, Gaps, and Hand-Off Problems 14
- Failure to rescue 4
- Identification Errors 3
- Delirium 1
- Medication Errors/Preventable Adverse Drug Events 16
- Nonsurgical Procedural Complications 1
- Overtreatment 2
- Psychological and Social Complications 29
- Second victims 2
- Surgical Complications 8
- Allied Health Services 1
- Internal Medicine 40
- Pediatrics 33
- Nursing 9
- Palliative Care 2
- Pharmacy 3
- Family Members and Caregivers
- Health Care Executives and Administrators 88
Health Care Providers
- Nurses 11
- Physicians 21
- Non-Health Care Professionals 44
- Patients 89
- Asia 2
- Australia and New Zealand 8
- Europe 17
- Canada 9
- United States of America 137
Search results for ""
Journal Article > Commentary
Clarkson MD, Haskell H, Hemmelgarn C, Skolnik PJ. BMJ. 2019;364:l1233.
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.
Journal Article > Commentary
Lifflander AL. JAMA. 2019;321:837-838.
Implementing new information systems can have unintended consequences on processes. This commentary explores insights from a physician, both as a clinician and as the family member of a patient, regarding the impact of hard stops in electronic health records intended to prevent gaps in data entry prior to task progression. The author raises awareness of the potential for patient harm due to interruptions and diminishing student and clinician skill in asking questions to build effective patient histories.
Dembosky A. All Things Considered and KQED. January 23, 2019.
Policy, practice, and communication strategies have been implemented in an effort to stem the opioid crisis and prescribing activities that contribute to misuse. This news article and accompanying webcast discuss an initiative in California that sends letters to prescribers whose patients have died due to opioid overdose. The piece outlines unintended consequences associated with the practice, including clinician reluctance to prescribe opioids for pain. An Annual Perspective discussed the patient safety aspects of the opioid epidemic.
Park A. Time Magazine. January 24, 2019.
This news article reports on the documentary To Err Is Human, which was produced and directed by the son of patient safety leader Dr. John M. Eisenberg. The film is structured around patient safety advocate Sue Sheridan's experience with diagnostic errors that resulted in harm for both her son and husband. It features a wide range of experts who discuss the impact of error on all involved, the role of culture in facilitating both mistakes and progress, and why continued work in health care safety is needed.
Journal Article > Commentary
Using a spare medication vial to store multiple medications: a potentially fatal in-home medication error.
Leonard JB, Klein-Schwartz W. Am J Health Syst Pharm. 2019;76:264-265.
Patient and family medication administration mistakes can result in medication errors at home. This commentary describes the problem of "pill dumping," where patients combine their daily medicines into a spare vial. However, patients are at risk for mistakenly taking a vial of a single medication instead of their pill-dump vial and inadvertently overdosing. The authors suggest medication counseling and use of daily pill boxes as tactics to prevent this type of error.
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.
Legislation/Regulation > Colorado Legislation
Pettersen B, Tate J, Tipper K, McKean H. Colorado Senate Bill 19-201.
Communication-and-resolution mechanisms are seen as important approaches to improving transparency and healing after an adverse event. This state bill, referred to as the "Colorado Candor Act," protects conversations between organizations, clinicians, patient, and families from legal discoverability and outlines criteria to guarantee that protection.
Journal Article > Commentary
Fitzsimons BT, Fitzsimons LL, Sun LR. Pediatrics. 2019;143:e20183458.
Rare diseases pose diagnostic challenges for physicians. This commentary offers insights from parents of a young child who died due to a delayed stroke diagnosis as well as from the patient's neurologist to raise awareness of childhood stroke and discuss the importance of partnership to heal from loss and advocate for improvement.
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.
Cullen A. Uitgeverij van Brug: The Hague, The Netherlands; 2019. ISBN: 9789065232236.
Patient stories offer important insights regarding the impact medical errors have on patients and their families. This book shares the author's experience with medical error and spotlights how lack of transparency in European health care can contribute to avoidable process failures that result in patient harm.
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.
Canadian Patient Safety Institute and Health Standards Organization.
This draft 5-year framework aims to guide the activities in Canada to focus action, resources, and policy development on supporting care improvement. The document is structured around five goals: people-centered care, safe care, accessible care, appropriate care, and continuous care. The authors invited Canadian patients, families, clinicians, organization leaders, and policymakers to provide input on the material to ensure its applicability across the country.
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.
Lives Lost, Lives Saved: An Updated Comparative Analysis of Avoidable Deaths at Hospitals Graded by The Leapfrog Group.
Austin M, Derk J. Baltimore, MD: Armstrong Institute for Patient Safety and Quality, and Johns Hopkins Medicine; May 2019.
Measures help track gaps in process and evidence of safety improvements. This white paper examines the performance of hospitals receiving Hospital Safety Grades and the relationship between high-level recognition and preventable harm. The report estimates that a substantial number of lives could have been saved if performance metrics had been met, but concludes that even high-performing hospitals exhibit areas in need of improvement.
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.
Colino S. Fam Circle. August 2019;132:66,69.
Patients and families can play a role in ensuring care is effective and safe. This news article recommends ways for patients to reduce risk of errors during a hospitalization, including using a patient portal to identify mistakes, asking questions, bringing an advocate, and working with hospitalists as key care partners.
Journal Article > Study
Consumers' perspectives on their involvement in recognizing and responding to patient deterioration—developing a model for consumer reporting.
King L, Peacock G, Crotty M, Clark R. Health Expect. 2019;22:385-395.