Narrow Results Clear All
- Communication Improvement 5
- Culture of Safety 4
- Education and Training 9
Error Reporting and Analysis
- Error Reporting 13
- Human Factors Engineering 11
- Legal and Policy Approaches 11
- Logistical Approaches 1
- Policies and Operations 1
- Quality Improvement Strategies 6
- Technologic Approaches 5
- Device-related Complications
- Diagnostic Errors 3
- Discontinuities, Gaps, and Hand-Off Problems 3
- Identification Errors 3
- Medical Complications 12
- Medication Safety 10
- Nonsurgical Procedural Complications 5
- Psychological and Social Complications 1
- Surgical Complications 14
- Allied Health Services 1
- Internal Medicine 14
- Nursing 3
- Pharmacy 3
Search results for ""
Journal Article > Commentary
Cohen T, Ellis WS, Morrissey JJ, Bakuzonis C, David Y, Paperman WD. J Healthc Inf Manag. Fall 2005;19:38-48.
After reviewing the literature and several case studies, the authors conclude that cell phones can be safely used in hospitals if steps are taken to avoid electromagnetic interference.
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.
Klein A. The Washington Post. December 11, 2005:A01.
This article reports on the reuse of single-use medical instruments, discussing both the benefits and risks of the practice.
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.
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.
St. Paul, MN: Minnesota Department of Health; January 2009.
This report provides background on the Minnesota Never Events reporting initiative, tips for patients on how to receive the safest care possible, and a table of events reported by all hospitals in the state.
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.
Landro L. Wall Street Journal. June 27, 2007:D3.
This article discusses errors associated with tubing misconnections in hospital-based care. A previous WebM&M commentary discussed a tubing error that led to administration of the wrong gas.
US News & World Report. July 3, 2008.
This article discusses the findings of a recent study that reported deficiencies in barcode systems requiring numerous overrides and "workarounds" by nurses.
Tarkan L. New York Times. September 14, 2008;Health section:7.
This article describes how medical errors may cause serious harm in pediatric patients and offers tips for hospitals and parents to foster safe treatment.
Landro L. Wall Street Journal (Eastern edition). December 23, 2008;D2.
Emphasizing the importance of safe device use to prevent patient harm, this article reports on the top 10 technology hazards in hospitals according to ECRI Institute's annual list, which includes alarm hazards, retained fragments, misleading displays, and surgical fires.
Fillo KT. Bureau of Health Care Safety and Quality, Department of Public Health. Boston, MA: Commonwealth of Massachusetts; July 2018.
This report compiles patient safety data documented by Massachusetts hospitals. The latest numbers represent a modest decrease in serious reportable events recorded in acute care hospitals, from 1012 the previous year to 922. This presentation also includes events from ambulatory surgery centers. Previous years reports are also available.
Tremlett G. Guardian.co.uk; July 13, 2009.
This newspaper article reports on a family that experienced two medical errors, resulting in the death of both a mother and her infant.
Rein L. Washington Post. July 21, 2009:E1.
This news article reports on Washington, DC–area initiatives to track preventable patient injury and discusses strategies to hold hospitals accountable to reduce the number of avoidable incidents.
Zarembo A. Los Angeles Times. October 15, 2009:A1.
This news piece describes communication gaps following a radiation overdose incident thought to involve more than 200 patients at one hospital.
Bogdanich W. New York Times. January 24, 2010:A1.
First in a series on medical radiation, this news feature and accompanying video investigate patient deaths and injuries following mistakes related to radiation treatment. The journalists discuss the number of radiation therapy errors in New York and reveal that state law does not require public reporting of such mistakes.
Consumer Reports. March 2010;75:16-21.
Kowalczyk L. Boston Globe. February 21, 2010.
This news account discusses a patient death after a heart monitor alarm was inadvertently turned off. Hospital and device safety experts weigh in on strategies to prevent these types of errors.
Rockville, MD: Agency for Healthcare Research and Quality.
In this annual publication, AHRQ reviews the results of the National Healthcare Quality Report and National Healthcare Disparities Report. Providing a 5-year update on the National Quality Strategy, this report highlights that a wide range of quality measures have shown improvement in quality, access, and cost.
Zarembo A. Los Angeles Times. April 6, 2010.
This newspaper article reports on device failures in the context of organizational and individual accountability for unreliable equipment, aborted surgery, and treatment delay.