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- Communication Improvement 1
- Education and Training 3
- Error Reporting and Analysis 4
- Human Factors Engineering
- Legal and Policy Approaches 2
- Quality Improvement Strategies 1
- Transparency and Accountability 1
- Family Members and Caregivers 2
- Health Care Executives and Administrators 7
- Health Care Providers 6
Non-Health Care Professionals
- Media 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.
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.
McFadden M. WNDU. February 21, 2012.
This news video reports on a death from patient-controlled analgesia and how graphic design students were consequently inspired to design materials to enhance awareness of pain-pump safety.
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.
Landro L. Wall Street Journal. January 4, 2016.
Alert fatigue is a well-known problem in hospitals. This newspaper article reports on efforts to reduce unnecessary alarms in hospitals to prevent staff from overlooking critical alerts. Highlighting strategies such as using secondary notification systems and recalibrating alerts according to the severity of physiologic change, the article also describes organizational guidelines to improve alarm safety. A recent WebM&M commentary explored how alarm fatigue can result in patient harm.
Mohr H, Weiss M. Associated Press. November 27, 2018.
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.
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.