Narrow Results Clear All
- Communication Improvement 3
- Culture of Safety 1
- Education and Training
- Error Reporting and Analysis 1
- Legal and Policy Approaches 1
- Quality Improvement Strategies 1
- Research Directions 1
- Technologic Approaches 1
Search results for ""
Cook RI, Woods DD, Miller C. Chicago, IL: National Patient Safety Foundation; 1998.
A report from a workshop, this document is a well-written look at the differences between "first stories" and "second stories" describing major errors. First stories are the easy one-person or one-cause accounts and reactions to critical incidents. "So-and-so forgot to check the patient's allergy history." Or "How could they have ignored the alarm and so many other red flags?" Even now, with some penetration of the concepts of systems thinking, it is still easy to fall back on the familiar and easy explanation of human error, missing key opportunities to fix underlying problems with processes of care or the way care is organized. Identifying such problems, however, requires the far richer "second stories" about such critical incidents, and these stories do not emerge without hard work. The authors have done this hard work for many publicized medical errors, drawing on follow-up newspaper articles and other investigative documents, often in far more obscure places than headlining first stories. Even readers familiar with root cause analysis will likely find value in many of the case studies. And, for those not familiar with such accident investigation techniques, the report provides a very readable introduction to their importance and a resource for further references.
Journal Article > Commentary
Development of a patient safety web-based education curriculum for physicians, nurses, and patients.
Hendee WR, Keating-Christensen C, Loh YH. J Patient Saf. 2005;1:90-99.
Tools/Toolkit > Toolkit
Building the Future for Patient Safety: Developing Consumer Champions—A Workshop and Resource Guide.
Chicago, IL: Consumers Advancing Patient Safety; 2007.
This guide describes the Consumers Advancing Patient Safety workshop process, which can be adapted and used to help consumers become active partners in patient safety work. Resources to be used during a workshop are also provided.
McIver SB, Wyndham R. Toronto, Canada: ECW Press; 2013. ISBN: 9781770411104.
This book includes stories of medical errors in Canada, shares patient and family perspectives, and discusses strategies to improve safety.
Tarkan L. New York Times. January 25, 2011:D1.
This newspaper article reports on the aging of the physician population and its potential risks to patient safety.
Higgins J. Akron Beacon Journal. September 2, 2011.
This news article reports on a medication safety training program for staff in Ohio public schools.
Audiovisual > Audiovisual Presentation
Health Research and Educational Trust. September 15, 2015.
Audiovisual > Audiovisual Presentation
National Academy of Medicine. December 10, 2015; National Academy of Sciences Building, Washington, DC.
In recognition of the 15th anniversaries since To Err Is Human and Crossing the Quality Chasm were published, this symposium discussed accomplishments and persisting challenges in the fields of patient safety and quality improvement since those reports were released. The session featured Dr. Donald Berwick, Dr. Lucian Leape, and Carolyn Clancy as speakers.
Journal Article > Study
Patients and families as teachers: a mixed methods assessment of a collaborative learning model for medical error disclosure and prevention.
Langer T, Martinez W, Browning DM, Varrin P, Sarnoff Lee B, Bell SK. BMJ Qual Saf. 2016;25:615-625.
Health systems struggle with how to effectively involve patients in safety efforts without placing undue responsibility or blame on them. Greater patient–clinician collaboration is particularly important for error disclosure because of the well-documented gaps in clinician and patient perspectives. In this study, investigators developed an intervention to have patients or family members teach error disclosure and prevention to interprofessional clinician learners, including physicians, nurses, and social workers. Their pre–post evaluation showed that the majority of patient and clinician participants reported improved communication and found the intervention valuable. Patient and clinician participation was voluntary. Although these results show promise for involving patients and families as teachers for error disclosure and prevention training, further work is needed to determine whether this approach will be effective among broader health care teams, as opposed to interested clinicians who volunteer. A related editorial discusses the challenges of including patients in safety efforts.
Web Resource > Multi-use Website
Indiana Hospital Association.
Launched in 2006, the Indiana Patient Safety Center (IPSC) is dedicated to promoting safety culture and reliable systems of care in the state. This website provides resources related to IPSC educational activities and efforts to raise awareness of local and national safety initiatives, including the Hospital Engagement Network.
CDC Vital Signs. August 23, 2016.