Narrow Results Clear All
- Patient Safety Primers 1
- WebM&M Cases 8
- Perspectives on Safety 7
- Commentary 49
- Review 6
- Study 71
- Slideset 2
- Book/Report 105
- Legislation/Regulation 13
- Newspaper/Magazine Article 556
- Newsletter/Journal 3
- Special or Theme Issue 9
- Glossary 1
- Toolkit 19
- Forum 1
- Award 7
- Clinical Guideline 1
- Grant 3
- Meeting/Conference 8
- Press Release/Announcement 31
Communication between Providers
- Sbar 1
- Communication between Providers 69
- Culture of Safety 70
Education and Training
- Students 5
Error Reporting and Analysis
- Never Events 14
- Error Reporting 208
Human Factors Engineering
- Checklists 29
Legal and Policy Approaches
- Regulation 52
- Logistical Approaches 42
- Policies and Operations 6
Quality Improvement Strategies
- Benchmarking 21
- Research Directions 5
- Specialization of Care 25
- Teamwork 25
- Clinical Information Systems 62
- Transparency and Accountability 18
- Alert fatigue 3
- Device-related Complications 53
- Diagnostic Errors 98
- Discontinuities, Gaps, and Hand-Off Problems 74
- Drug shortages 13
- Failure to rescue 3
- Fatigue and Sleep Deprivation 17
- Identification Errors 47
- Interruptions and distractions 3
- Delirium 1
- Medication Errors/Preventable Adverse Drug Events 151
- MRI safety 1
- Nonsurgical Procedural Complications 18
- Overtreatment 6
- Psychological and Social Complications 71
- Surgical Complications 144
- Transfusion Complications 4
- Home Care 20
- General Hospitals 175
- Long-Term Care 14
- Outpatient Surgery 17
- Patient Transport 2
- Psychiatric Facilities 5
- Allied Health Services 2
- Geriatrics 20
- Obstetrics 20
- Pediatrics 68
- Primary Care 18
- Radiology 16
- Internal Medicine 240
- Nursing 28
- Palliative Care 3
- Pharmacy 109
- Family Members and Caregivers 87
- Health Care Executives and Administrators 348
Health Care Providers
- Nurses 35
- Pharmacists 28
- Physicians 111
Non-Health Care Professionals
- Educators 25
- Engineers 12
- Media 20
- Policy Makers 110
- Australia and New Zealand 14
- Europe 67
- Canada 29
United States of America
United States Federal Government
- Department of Health and Human Services (HHS) 100
- United States Federal Government 111
Search results for ""
Gawande A. New Yorker. November 12, 2018.
In this magazine article, Atul Gawande describes a range of frustrations physicians experience as digitization becomes more widespread in health care. He elaborates upon several elements of electronic health record use that can degrade care processes and create conditions for errors, such as burnout, lack of patient-centeredness, and alert fatigue.
Palo Alto, CA: Gordon and Betty Moore Foundation; November 1, 2018.
Missed or delayed diagnoses lead to delays in care and significant preventable harm for patients. Despite an increasing focus on diagnostic error, accurate measurement and implementation of effective strategies for mitigating its adverse effects remain challenging. The Gordon and Betty Moore Foundation recently announced a new $85 million initiative focused on diagnostic excellence that takes into account health care costs, timeliness, and individual patient needs. This initiative will focus on three clinical areas including cancer, infections, and cardiovascular events. Through this funding, the foundation hopes to stimulate novel approaches to measuring diagnostic performance and plans to assess the effectiveness of new technologies in improving the diagnostic process. A PSNet perspective highlighted ongoing challenges related to diagnostic error.
Mohr H, Weiss M. Associated Press. November 27, 2018.
Canadian Patient Safety Institute. October 2018.
Gordon M. Health Shots. National Public Radio. April 10, 2019.
Punitive responses to medical errors persist despite continued efforts to reduce them. This news article reports on an incident involving the mistaken use of a neuromuscular blocking agent that resulted in the death of a patient, the prosecution of the nurse who made the error, and systemic and human factors that contribute to similar events.
Journal Article > Study
Making infection prevention and control everyone's business? Hospital staff views on patient involvement.
Sutton E, Brewster L, Tarrant C. Health Expect. 2019 Feb 17; [Epub ahead of print].
Interviews with frontline hospital staff and executive leaders revealed that they were generally supportive of engaging families and patients to promote infection prevention in the clinical setting when using a collaborative approach. Staff identified certain challenges including concerns related to the extent of responsibility patients and families should bear with regard to infection prevention as well as risks to infection control posed by patients themselves.
Rau J. Kaiser Health News. March 1, 2019.
Financial incentives may encourage adoption of practice improvements that enhance safety. This news article reports on the increase in United States hospitals that have had Medicare payments withheld due to high rates of hospital-acquired conditions. The article is accompanied by a state-level tally of individual hospitals penalized.
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.
FDA identifies harm reported from sudden discontinuation of opioid pain medicines and requires label changes to guide prescribers on gradual, individualized tapering.
Silver Spring, MD: US Food and Drug Administration; April 9, 2019.
Efforts to address the opioid epidemic range from regulation to changes in pain management. This safety announcement raises awareness of potential harms associated with rapidly decreasing the dose of or discontinuing opioids for patients who may be physically dependent on the medication. It also announces a requirement regarding changes to prescribing information for opioids to provide expanded guidance on how to safely taper doses. Health care providers should discuss tapering plans with patients and provide ongoing monitoring and support.
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.
FDA Safety Communication: caution when using robotically-assisted surgical devices in women's health including mastectomy and other cancer-related surgeries.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; February 28, 2019.
This announcement seeks to raise awareness of the potential risks associated with the use of robotic-assisted surgical devices in mastectomies or cancer-related care. Recommendations for patients who may seek to have robotically assisted surgery include asking about their surgeon's experience with these procedures and discussing benefits, risks, and alternatives regarding available treatment options with their health care provider. Suggestions for health care providers include completing specialized training on procedures they perform. A WebM&M commentary described the challenges and benefits associated with robotic surgery.
Topol E. New York, NY: Basic Books; 2019. ISBN: 978-1541644632.
This book explores how advancements in technology can improve decision making but may also diminish patient-centered care. The author discusses the potential of big data, artificial intelligence, and machine learning to enhance diagnosis and care delivery. A past PSNet interview with the author, Eric Topol, talked about the role of patients in the new world of digital health care.
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.
Web Resource > Multi-use Website
American Hospital Association.
Maternal harm is a patient safety concern that is increasingly prioritized in regulatory and care delivery environments. This website provides tools, policies, news articles, case studies, and information for patients and families to inform efforts to protect mothers and infants across geographic regions.
Journal Article > Commentary
Using a spare medication vial to store multiple medications: a potentially fatal in-home medication error.
Leonard JB, Klein-Schwartz W. Am J Health Syst Pharm. 2019;76:264-265.
Patient and family medication administration mistakes can result in medication errors at home. This commentary describes the problem of "pill dumping," where patients combine their daily medicines into a spare vial. However, patients are at risk for mistakenly taking a vial of a single medication instead of their pill-dump vial and inadvertently overdosing. The authors suggest medication counseling and use of daily pill boxes as tactics to prevent this type of error.
Chisholm P. Health Shots. National Public Radio. February 27, 2019.
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.
Dickson EJ. Rolling Stone. March 9, 2019.
Unintended consequences of restrictions enacted to combat the opioid crisis are a concern for patients and prescribers. This magazine article reports on an effort to raise awareness of the potential for patient harm due to lack of legitimate access to opioids for chronic pain as a result of the 2016 CDC opioid prescribing guidelines.
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.