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- WebM&M Cases 2
- Study 7
- Audiovisual 5
- Book/Report 5
- Newspaper/Magazine Article 48
- Special or Theme Issue 1
- Glossary 1
- Toolkit 4
- Web Resource 9
- Grant 1
Communication between Providers
- Sbar 1
- Communication between Providers 22
- Culture of Safety 3
Education and Training
- Students 1
- Error Reporting and Analysis 15
- Human Factors Engineering 5
- Legal and Policy Approaches 17
- Logistical Approaches 11
- Quality Improvement Strategies 17
- Specialization of Care 4
- Teamwork 2
- Clinical Information Systems 10
- Transparency and Accountability 1
- Device-related Complications 4
- Diagnostic Errors 11
- Discontinuities, Gaps, and Hand-Off Problems
- Fatigue and Sleep Deprivation 4
- Identification Errors 5
- Medical Complications 6
- Medication Safety 19
- Nonsurgical Procedural Complications 1
- Psychological and Social Complications 3
- Surgical Complications 5
- Ambulatory Care 11
- General Hospitals 14
- Long-Term Care 1
- Outpatient Surgery 1
- Patient Transport 1
- Internal Medicine 21
- Nursing 2
- Pharmacy 5
- Family Members and Caregivers 7
- Health Care Executives and Administrators 31
Health Care Providers
- Nurses 5
Non-Health Care Professionals
- Media 1
Search results for ""
Cases & Commentaries
- Web M&M
Glenn Flores, MD; April 2006
With no one to interpret for them and pharmacy instructions printed only in English, nonEnglish-speaking parents give their child a 12.5-fold overdose of a medication.
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.
Weber T, Ornstein C. Los Angeles Times. April 12, 2005.
This article reports on a death that occurred at the Martin Luther King Jr./Drew Medical Center after a patient's deteriorating vitals signs went unnoticed.
Fischman J. US News and World Report. August 1, 2005;139:45,49-50,52.
This article reports on activities at several hospitals that illustrate how information technology can help improve the safety of health care.
Meisel Z. Slate. November 8, 2005.
In this article, an emergency medicine physician describes the work environment of emergency medical technicians and paramedics and why it is prone to error.
Berwick DM. Newsweek. December 12, 2005;46:75-78.
Institute for Healthcare Improvement President Don Berwick summarizes the six improvement measures of the 100K Lives Campaign.
Dublin, Ireland: Irish Society for Quality & Safety in Healthcare; 2005.
This report provides results from a 26-hospital survey investigating areas of service and care weakness in Irish hospitals. The research revealed problems related to information transfer, overwork, and lack of patient involvement in decision making about their care.
Hua V. San Francisco Chronicle. February 17, 2006:B6.
This article reports on a study conducted by the Discrimination Research Center that found non-English speakers were not connected to a staff member who spoke the language in about half of calls to the emergency department.
Institute for Healthcare Improvement Web site. March 20, 2006.
This article reviews the importance of medication reconciliation, discusses the difficulties of building the process into patient care, and shares stories from hospitals that have successfully implemented programs.
Feldman R. The Washington Post. May 2, 2006:HE01.
In this article, a nurse shares her firsthand account of what it was like to be a surgical patient and the surprising safety and quality shortcomings she encountered during her hospital stay.
Stout D. New York Times. June 17, 2006;National desk:9.
This article reports on the investigation following the death of New York Times reporter David E. Rosenbaum. The investigation uncovered a range of failures in emergency care and is described in a report available via the link below.
Landro L. Wall Street Journal (Eastern edition). June 28, 2006:D1. [reprinted on Post-gazette.com].
This article reports on communication interventions such as SBAR (Situation-Background-Assessment-Recommendation) that make patient hand-offs more reliable.
Scathing report on Kaiser kidney program. Transplant delays assailed -- Medicare threatens to end coverage.
Russell S. San Francisco Chronicle. June 24, 2006.
This article reports on a Centers for Medicare & Medicaid Services report that details deficiencies in Kaiser's kidney transplant program.
Journal Article > Study
Coleman EA, Parry C, Chalmers S, Min SJ. Arch Intern Med. 2006;166:1822-1828.
Prior studies have documented the safety problems that befall patients with complex illnesses at the time of transition from one setting of care to another. In this trial conducted in an integrated delivery system, patients were randomized to receive usual care or the care transitions intervention at the time of hospital discharge. Intervention patients received a personal health record and a "transition coach," who assisted with continuity of care across settings, arranged home visits after discharge, and helped train patients and caregivers in self-care methods. The foci of the intervention were on ensuring accurate medication usage and appropriate follow-up care. The intervention successfully reduced the likelihood of hospital readmission for 3 months after discharge and appeared to be cost effective.
Gulliver D. Sarasota Herald Tribune. November 7, 2006:BS1.
This article reports on the death of a restrained patient and outlines the factors affecting the subsequent reporting of the event.
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.
Holt TE. Men's Health. November 3, 2006.
This series includes articles on "doorway diagnosis" (or a doctor's assessment of a patient before an exam begins), anesthesiologists addicted to painkillers, and medical mistakes in the emergency room.
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.
Lerner BH. The Washington Post. November 28, 2006:HE01.
The author reviews the legacy of Libby Zion and how her untimely death raised awareness of the impact that resident duty hours and fatigue could have on patient care and quality.
Parker L. USA Today. December 19, 2006.
This article reports on the case of an elderly patient whose advance directive wasn't followed and discusses the impact of this omission.