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Cases & Commentaries
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Dean Schillinger, MD; March 2004
A misunderstanding of instructions on how to administer medication leads to an infant choking on a syringe cap.
Patient Safety Primers
Anyone can find it challenging to understand medical terms, and millions of Americans have trouble understanding and acting upon health information. The mismatch between individuals' health literacy skills and the complexity of health information and health care tasks involved in managing health has implications on patient safety.
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.
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.
Chen PW. New York Times. October 1, 2009.
This column discusses how life stresses affect the reliability and safety of care provided by over-extended clinicians in light of a recent study on the topic.
Journal Article > Study
Patients' attitudes towards patient involvement in safety interventions: results of two exploratory studies.
Davis RE, Sevdalis N, Pinto A, Darzi A, Vincent CA. Health Expect. 2013;16:e164-e176.
An educational intervention increased the likelihood that patients would participate in safety behaviors, such as asking providers about hand hygiene. Proposed roles for patients in patient safety are discussed in more detail in this Patient Safety Primer.
Chen PW. New York Times. April 18, 2013.
Dunklin R, Goetinck Ambrose S, Egerton B. Dallas Morning News. August 1, 2010:A01.
This newspaper article reveals how one teaching hospital facilitated error through ineffective resident training, weak oversight, and poor safety culture.
Yurkiewicz I. Aeon Magazine. January 29, 2014.
Disruptive behavior is a well-known and pervasive issue in health care. Describing disrespectful behaviors that clinicians face, such as sarcasm and intimidation, this magazine article emphasizes how they can hinder effective interactions and communication to reduce patient safety.
Boodman SG, Kaiser Health News. Washington Post. May 19, 2014.
Khullar D. New York Times. May 15, 2014.
Journal Article > Study
Patients and families as teachers: a mixed methods assessment of a collaborative learning model for medical error disclosure and prevention.
Langer T, Martinez W, Browning DM, Varrin P, Sarnoff Lee B, Bell SK. BMJ Qual Saf. 2016;25:615-625.
Health systems struggle with how to effectively involve patients in safety efforts without placing undue responsibility or blame on them. Greater patient–clinician collaboration is particularly important for error disclosure because of the well-documented gaps in clinician and patient perspectives. In this study, investigators developed an intervention to have patients or family members teach error disclosure and prevention to interprofessional clinician learners, including physicians, nurses, and social workers. Their pre–post evaluation showed that the majority of patient and clinician participants reported improved communication and found the intervention valuable. Patient and clinician participation was voluntary. Although these results show promise for involving patients and families as teachers for error disclosure and prevention training, further work is needed to determine whether this approach will be effective among broader health care teams, as opposed to interested clinicians who volunteer. A related editorial discusses the challenges of including patients in safety efforts.
Landro L. Wall Street Journal. August. 8, 2016.
First-year residents may be reluctant to ask for assistance due to factors such as peer pressure to demonstrate competency. This newspaper article reports on one hospital's strategy to enhance communication among residents and attendings, which encourages residents to ask questions of senior clinicians who are coached to welcome learning conversations.
Hurt J. Med Econ. April 26, 2017.
CDC Vital Signs. May 7, 2019.
Maternal morbidity and mortality is a worldwide patient safety problem. This analysis describes the prevalence of pregnancy-related death and areas of concern during pregnancy, at delivery, and up to a year postpartum. It reports that 60% of these deaths are preventable and provides suggestions for families, clinicians, and systems to reduce risks.