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- Communication Improvement 2
- Culture of Safety 1
- Education and Training 2
- Error Reporting and Analysis 3
- Human Factors Engineering 6
- Legal and Policy Approaches 1
- Quality Improvement Strategies 2
- Technologic Approaches 1
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Cases & Commentaries
- Web M&M
Dean Schillinger, MD; March 2004
A misunderstanding of instructions on how to administer medication leads to an infant choking on a syringe cap.
King K. Silicon Valley/San Jose Business Journal. April 15, 2005: In Depth: Structures section.
The vice president of facilities at El Camino Hospital discusses the opportunity for building a facility that will improve patient care and employee productivity.
Wojcieszak D. Patient Safety Qual Healthc. May/June 2005;2:6, 8-9.
The author, who lost his brother to medical error, reflects on his family's frustrating experience with the hospital and legal system. He proposes that the medical profession can learn valuable lessons from the engineering safety culture.
Kerber R. The Boston Globe. June 23, 2005;Business section:E1.
This article reports on problems with medical devices and discusses whether manufacturers should directly notify patients regarding defects.
Borzo J. Wall Street Journal. May 23, 2005:R10.
This article discusses decision support system implementation and use, and its role in preventing physician misdiagnosis.
Knox R. Morning Edition. National Public Radio. January 27, 2014.
McFarling UL. STAT. September 7, 2016.
Intensive care units (ICUs) are complex environments that harbor various challenges to safe care delivery. Reporting on alarm fatigue and insufficient interoperability between devices in ICUs, this news article describes solutions to address data overload and highlights the efforts of several hospitals working toward developing ICUs that are more respectful of patients and the clinical teams caring for them.
US Food and Drug Administration. March 8, 2019.
Errors of commission during complex procedures can contribute to patient harm. Drawing from an analysis of medical device reports submitted to the Food and Drug Administration, this announcement seeks to raise awareness of common adverse events associated with surgical staplers and implantable staples. User-related problems include opening of the staple line, misapplied staples, and staple gun difficulties. Recommendations include ensuring availability of various staple sizes and avoiding use of staples on large blood vessels.