Narrow Results Clear All
- Communication Improvement 15
- Culture of Safety 2
- Education and Training 6
- Error Reporting and Analysis 17
- Human Factors Engineering 3
- Legal and Policy Approaches 1
- Logistical Approaches 2
- Quality Improvement Strategies 9
- Research Directions 1
- Specialization of Care 2
- Teamwork 1
- Technologic Approaches 5
- Device-related Complications 1
- Discontinuities, Gaps, and Hand-Off Problems 5
- Fatigue and Sleep Deprivation 1
- Identification Errors 3
- Medical Complications 3
- Medication Errors/Preventable Adverse Drug Events 6
- Nonsurgical Procedural Complications 1
- Psychological and Social Complications 1
- Surgical Complications 3
- Surgery 3
- Nursing 1
- Palliative Care 1
- Pharmacy 2
- Family Members and Caregivers 7
- Health Care Executives and Administrators
Health Care Providers
- Nurses 6
Non-Health Care Professionals
- Media 2
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Cases & Commentaries
- Web M&M
Dean Schillinger, MD; March 2004
A misunderstanding of instructions on how to administer medication leads to an infant choking on a syringe cap.
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.
Scanning out medication errors: Ohio Valley Hospital's automated IV system provides real-time access to patient data.
Carbasho T. Pittsburgh Business Times. April 25, 2005.
This article reports on Ohio Valley General Hospital's intravenous safety system. Using bar code scanning to provide important patient information, the system automates checks for intravenous medication administration.
Hospital-error oversight called lax: state takes too long to investigate mistakes, patient advocates say.
Galloway A. Seattle Post-Intelligencer. May 5, 2005.
This article explores inefficiencies in the process for reporting and investigating adverse events in Washington and indicates that inconsistent error review is a problem across the nation.
Weise E. USA Today. May 18, 2005.
Scobie S, Thomson R. London, England: National Patient Safety Agency; 2005.
Created in 2001 to institute changes in health care across the United Kingdom, the National Patient Safety Agency (NPSA) presents their first report of patient safety incidents. The two-part report begins with a general discussion of incident reporting, the basis for a national reporting system, and the development of the Patient Safety Observatory. The second part builds on this framework by discussing how the acquired data can be used and translated into safer health care strategies. The report itself encompasses more than 85,000 collected incident reports with analysis, comparisons, and case studies to illustrate important safety issues for future efforts. This represents the first of a series of expected reports from NPSA on patient safety data to be published.
Kowalczyk L. The Boston Globe. July 24, 2005.
This article reports on a proposed disclosure policy among Harvard Medical School teaching hospitals. The policy would outline a process for discussing error with patients and for training physicians on how to apologize.
Tools/Toolkit > Multi-use Website
Johns Hopkins University, Department of Anesthesiology & Critical Care Medicine.
This Web site provides information on the multidisciplinary safety team at Johns Hopkins University, including research projects, presentations, and useful tools for patients, families, and practitioners.
Journal Article > Commentary
Sachs BP. JAMA. 2005;294:833-840.
Part of a series in JAMA entitled Clinical Crossroads, this case study discusses the unfortunate events surrounding a 38-year-old woman's presentation to a labor and delivery unit. The case details a seemingly routine full-term pregnancy that rapidly evolved into a course of complications, ultimately leading to a fetal death, a hysterectomy, and a prolonged hospital course. The discussion shares the experience through the eyes of the patient, her husband, and the primary obstetrician. Further exploration of the case identified several specific factors and broader systems issues that contributed to the events. The author shares how this particular institution responded with overarching changes, including a greater emphasis on teamwork, communication, and appropriate staffing of labor and delivery units to promote safety.
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.
Kowalczyk L. The Boston Globe. November 27, 2005:A1.
This article reports on the implementation of rapid response teams in Boston hospitals and the potential for reducing patient mortality.
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.
Journal Article > Study
Error or "act of God"? A study of patients' and operating room team members' perceptions of error definition, reporting, and disclosure.
Espin S, Levinson W, Regehr G, Baker GR, Lingard L. Surgery. 2006;139:6-14.
This study discovered both similarities and differences in the way surgeons, nurses, anesthesiologists, and patients responded to four scripted clinical error scenarios. Findings suggested that all groups incorporated a negative outcome or a deviation from standard of practice into their error definition rather than analyzing the event independent of those factors. In addition, noted differences existed between patients who supported reporting for all negative events and nurses who believed in selective reporting. Similarly, persistent gaps existed between the full disclosure patients expect and the partial disclosure health professionals believe should occur. While the study represents a small sample size from two tertiary institutions, it does emphasize the importance of a safety culture and the need to redefine errors as opportunities for learning and improvement rather than individual or isolated events.
Web Resource > Multi-use Website
Dallas, TX: American College of Emergency Physicians.
This Web site provides access to emergency medical services evaluations in four categories: access, quality and patient safety, public health and prevention, and medical liability environment. The site also offers an interactive map of the nation, with detailed information and a "grade" for each state.
Journal Article > Study
Wolosin RJ, Vercler L, Matthews JL. J Nurs Care Qual. 2006;21:30-38.
This descriptive survey of more than 600,000 patients discovered that close to 90% rated their degree of safety and security in the hospital as good or very good. Factors associated with higher safety ratings included being an older man or younger woman, staying in a private room, having a shorter length of stay, and receiving greater amounts of information. The authors discuss strategies that hospitals might take to improve their patients' perception of safety, which include greater attention to communication practices, particularly regarding medications and hand washing.
Tools/Toolkit > Fact Sheet/FAQs
Ann Arbor, MI: VA National Center for Patient Safety; 2006.
This pamphlet informs consumers on steps both patients and clinicians should take prior to surgery to ensure safety.
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.
Chun D. Gainsville Sun. August 21, 2006.
This article describes a computerized drug ordering and dispensing system at a Florida hospital.
Paterson R. Auckland, New Zealand: Office of the Health and Disability Commissioner; April 24, 2007.
This report analyzes an incident of medication error that led to a patient's death, discusses the subsequent actions taken by the health board, and calls for a coordinated approach to medication reconciliation in New Zealand.
Journal Article > Study
Makary MA, Al-Attar A, Holzmueller CG, et al. N Engl J Med. 2007;356:2693-2699.
This survey revealed that nearly all surgical residents experience a needlestick injury during their training, but the majority are not reported. Feeling "rushed" or fatigued was a frequent contributing factor to needlesticks.