Narrow Results Clear All
- Communication Improvement 2
- Culture of Safety 3
- Education and Training 1
- Error Reporting and Analysis
- Human Factors Engineering 1
- Legal and Policy Approaches 7
- Logistical Approaches 2
- Policies and Operations 1
- Quality Improvement Strategies 2
- Transparency and Accountability
- Device-related Complications 1
- Diagnostic Errors 3
- Discontinuities, Gaps, and Hand-Off Problems 1
- Failure to rescue 1
- Identification Errors 1
- Medical Complications 1
- Medication Safety 1
- Nonsurgical Procedural Complications 1
- Surgical Complications 3
- Medicine 12
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Award > Award Recipient
Apold J, Daniels T, Sonneborn M. Jt Comm J Qual Patient Saf. 2006;32:672-675.
This article discusses the efforts of the Minnesota Alliance for Patient Safety to promote a culture of safety among the state's health care organizations.
Gulliver D. Herald Tribune. September 3, 2007.
This article describes how the culture around medical errors is evolving to include disclosure and transparency, illustrated by a physician's willingness to discuss a wrong-site surgery.
Errors test openness at Beth Israel Deaconess. Disclosures will benefit hospital, president insists.
Wen P. Boston Globe. October 27, 2008.
This newspaper article reports on one hospital executive's work on transparency regarding errors and describes reactions to these efforts.
Kauffman M, Altimari D. The Hartford Courant. November 15, 2009;Final:A1.
This newspaper article reports that a Connecticut law intended to make hospital errors more transparent has had the opposite effect by making it easier for hospitals to limit publicly available information on adverse events.
The Empowered Patient Coalition; 2010.
This video series uses two real cases of patients who died due to preventable errors after elective surgery to illustrate fundamental concepts in patient safety and provide lessons for patients and families in engaging in their own care. The circumstances leading to the death of Lewis Blackman, one of the patients discussed in this video series, are discussed in more detail in a separate article that analyzes his death as an example of failure to rescue.
Web Resource > Government Resource
Washington State Department of Health.
This Web site provides never event data to promote transparency and informed consumer decision making.
Bogdanich W, Rebelo K. New York Times. December 28, 2010;A1.
This article explores inaccuracy of dosage, lack of protocol adherence, and absence of transparency as trends that hinder learning from radiological adverse events.
Judd A. The Atlanta Journal-Constitution. November 20, 2011.
Makary M. New York, NY: Bloomsbury Press; 2012. ISBN: 9781608198368.
Hixenbaugh M, Ornstein C. Houston Chronicle and Propublica.
This news investigation chronicles a series of incidents in a transplant program that resulted in patient harm. The systemic nature of the problems such as insufficient whistleblower protection, accountability, and follow-up on patient concerns culminated in a change of hospital leadership. A previous PSNet interview with Charles Ornstein discussed the role of media in raising awareness of patient safety issues.
Park A. Time Magazine. January 24, 2019.
This news article reports on the documentary To Err Is Human, which was produced and directed by the son of patient safety leader Dr. John M. Eisenberg. The film is structured around patient safety advocate Sue Sheridan's experience with diagnostic errors that resulted in harm for both her son and husband. It features a wide range of experts who discuss the impact of error on all involved, the role of culture in facilitating both mistakes and progress, and why continued work in health care safety is needed.
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.
Legislation/Regulation > Colorado Legislation
Pettersen B, Tate J, Tipper K, McKean H. Colorado Senate Bill 19-201.
Communication-and-resolution mechanisms are seen as important approaches to improving transparency and healing after an adverse event. This state bill, referred to as the "Colorado Candor Act," protects conversations between organizations, clinicians, patient, and families from legal discoverability and outlines criteria to guarantee that protection.
Cullen A. Uitgeverij van Brug: The Hague, The Netherlands; 2019. ISBN: 9789065232236.
Patient stories offer important insights regarding the impact medical errors have on patients and their families. This book shares the author's experience with medical error and spotlights how lack of transparency in European health care can contribute to avoidable process failures that result in patient harm.
Palmer J. Patient Saf Qual Healthc. May/June 2019.
Organizations must learn from adverse events to prevent similar incidents. Reporting on lessons to be learned from the cascade of failures connected with the preventable death of a patient during an acute asthma attack at the door of a hospital emergency department, this magazine article outlines the importance of effective signage, appropriate security staff placement, and acceptance of the responsibility for failure.
Rein L. Washington Post. August 30, 2019.