Narrow Results Clear All
- Communication Improvement 22
- Culture of Safety 4
Education and Training
- Students 1
- Error Reporting and Analysis 12
- Human Factors Engineering 3
- Legal and Policy Approaches 13
- Logistical Approaches 4
- Quality Improvement Strategies 7
- Specialization of Care 2
- Teamwork 2
- Clinical Information Systems
- Transparency and Accountability 1
- Alert fatigue 2
- Device-related Complications 2
- Diagnostic Errors 13
- Discontinuities, Gaps, and Hand-Off Problems 10
- Failure to rescue 1
- Identification Errors 4
- Medical Complications 1
- Medication Errors/Preventable Adverse Drug Events 18
- Psychological and Social Complications 4
- Surgical Complications 2
- Internal Medicine 9
- Pharmacy 9
- Family Members and Caregivers 3
- Health Care Executives and Administrators 22
Health Care Providers
- Nurses 1
- Physicians 12
- Non-Health Care Professionals 39
Search results for ""
Cases & Commentaries
- Web M&M
Russ Cucina, MD, MS; July 2006
Despite full documentation and a wristband regarding her severe food allergy, an inpatient is advertently fed eggs and suffers an allergic reaction.
Perspectives on Safety > Annual Perspective
with commentary by Rachel J. Stern, MD, and Urmimala Sarkar, MD, 2017
Patient engagement in safety has evolved from obscurity to maturity over the past two decades. This Annual Perspective highlights emerging approaches to engaging patients and caregivers in safety efforts, including novel technological innovations, and summarizes the existing evidence on the efficacy of such approaches.
Washington, DC: Leapfrog Group.
This website offers resources related to the Leapfrog Hospital Survey investigating hospitals' progress in implementing specific patient safety practices. Updates to the survey include increased time allotted to complete computerized provider order entry evaluation, staffing of critical care physicians on intensive care units, and use of tools to measure safety culture. Reports discussing the results are segmented into specific areas of focus such as health care-associated infections and medication errors.
Journal Article > Commentary
Delbanco T, Berwick DM, Boufford JI, et al. Health Expect. 2001;4:144-150.
This viewpoint presents a summary of recommendations from the 1998 Salzburg Seminar entitled “Through the Patient’s Eyes.” The purpose of this seminar series is to offer a neutral forum for discussing beliefs on a variety of topics. The 5-day seminar was attended by 64 individuals from 29 different countries with a mission to create a health care system for a mythical republic called PeoplePower. The premise builds on a principle of “nothing about me without me,” as teams of health professionals, patient advocates, artists, reporters, and social scientists established a conceptual model. The authors share the participants’ visions of an ideal clinician-patient relationship and the role hospitals, national and local governmental agencies, and communities play in supporting such a model. Although they conclude that their health care system remains detached from financial, historical, and societal restraints, the principles serve as reminders that health programs must draw closer together patients and those who care for them.
Boodman SC. Washington Post. March 22, 2005:HE01.
Computerized provider order entry is revealed to have its own set of problems.
Journal Article > Study
Porter SC, Kohane IS, Goldmann DA. J Am Med Inform Assoc. 2005;12:299-305.
This study examined the utility of a multimedia kiosk to capture parents' knowledge of their children's asthma medication history. Investigators compared the parental information with that documented by emergency department providers. Results suggested greatest accuracy in medication name followed by route of delivery, form of medication, and dose. The authors conclude that patient-derived data can be effective in improving current deficits in medication documentation during emergency department visits.
Young D. Am J Health Syst Pharm. 2005;62:1340-1342.
This article summarizes comments made at the second meeting of the Committee on Identifying and Preventing Medication Errors. Topics covered include teamwork, engaging patients, medication reconciliation, access to information, and hospital design.
Wherry R. Forbes Magazine. June 20, 2005.
This article uses examples from several hospitals to illustrate the behavioral and financial issues involved in implementing information technologies such as electronic health records and order entry systems.
BBC News. August 9, 2005.
This article reports on a prototype electronic wristband that checks medications against a patient's prescription.
Gray R. Scotland on Sunday. January 8, 2006.
This story discusses the impact of a computer glitch in a system used by more than 80% of general practitioners in Scotland. In addition to physician notes being inadvertently attached to the wrong patient's medical record, reports suggest that some patients actually received incorrect prescriptions due to printing errors caused by the system.
Gibbs N, Bower A. Time Magazine. May 1, 2006.
This article takes an unusual look at the problem of medical errors: the perspective of physicians when they or a loved one is the patient. Even physicians well versed in the safety field find that they have relatively little control over the hospital environment and few ways to make their care safer. As the cover piece of Time magazine, this article is likely to generate considerable public discussion.
San Francisco, CA: The Leapfrog Group; May 2, 2006.
This news release announces that 22 California hospitals have been recognized for their achievements in addressing The Leapfrog Group's standards of quality and safety.
Stires D. Fortune Magazine. May 15, 2006:130-132, 134, 136.
This article reports on the U.S. Veterans Health Administration's successful adoption of health information technology and how it has improved care.
Evanston, IL: Office of the Governor; July 13, 2006.
This news release announces the governor's plans to improve patient safety in Illinois, including the use of e-prescribing by all providers and a Division of Patient Safety within the state public health department.
Committee on Identifying and Preventing Medication Errors, Aspden P, Wolcott J, Bootman JL, Cronenwett LR, eds. Washington, DC: The National Academies Press; 2007.
A major report by the Institute of Medicine (IOM) on medication errors suggests that, despite all the progress in patient safety since To Err is Human, medication errors remain extremely common, and the health care system can do much more to prevent them. Among the startling statistics from this report: more than 1.5 million Americans are injured every year in American hospitals, and the average hospitalized patient experiences at least one medication error each day. The report emphasizes actions that health care systems, providers, funders, and regulators can take to improve medication safety. These actions include having all US prescriptions written and dispensed electronically by 2010, more widespread use of medication reconciliation, and additional research on drug errors and how to prevent them. Importantly, the report also emphasizes actions that patients can take to prevent medication errors, such as maintaining active medication lists and bringing their medications to appointments. Support for the IOM report came from the Centers for Medicare & Medicaid Services.
Arnst C. Business Week. July 17, 2006.
This article discusses improvements made at U.S. Veterans Affairs' hospitals as well as unique elements of the system that support safe and high-quality care.
Knox R. "All Things Considered." National Public Radio. July 20, 2006.
This story discusses findings from the 2006 Institute of Medicine report on medication errors and includes interviews with James Conway and Michael Cohen.
Chun D. Gainsville Sun. August 21, 2006.
This article describes a computerized drug ordering and dispensing system at a Florida hospital.
Grant > Government Resource
Rockville, MD: Agency for Healthcare Research and Quality; June 2008.
This announcement describes the 19 projects funded by the Agency for Healthcare Research and Quality in 2006 that studies the potential of simulation to improve patient safety.
Landro L. Wall Street Journal (Eastern edition). November 29, 2006: D1-D5. [Reprinted on Post-gazette.com].
This article describes a decision support program used by Kaiser Permanente and U.S. Veterans Administration to help minimize misdiagnosis.