Narrow Results Clear All
- Communication Improvement 12
- Culture of Safety 3
Education and Training
- Students 1
- Error Reporting and Analysis 5
- Human Factors Engineering 2
- Legal and Policy Approaches 6
- Logistical Approaches 1
- Quality Improvement Strategies 2
- Teamwork 2
- Clinical Information Systems
- Transparency and Accountability 1
- Alert fatigue 1
- Device-related Complications 1
- Diagnostic Errors 1
- Discontinuities, Gaps, and Hand-Off Problems 6
- Identification Errors 1
- Medication Safety 7
- Psychological and Social Complications 3
- Surgical Complications 1
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Perspectives on Safety > Annual Perspective
with commentary by Rachel J. Stern, MD, and Urmimala Sarkar, MD, 2017
Patient engagement in safety has evolved from obscurity to maturity over the past two decades. This Annual Perspective highlights emerging approaches to engaging patients and caregivers in safety efforts, including novel technological innovations, and summarizes the existing evidence on the efficacy of such approaches.
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.
Journal Article > Study
Porter SC, Kohane IS, Goldmann DA. J Am Med Inform Assoc. 2005;12:299-305.
This study examined the utility of a multimedia kiosk to capture parents' knowledge of their children's asthma medication history. Investigators compared the parental information with that documented by emergency department providers. Results suggested greatest accuracy in medication name followed by route of delivery, form of medication, and dose. The authors conclude that patient-derived data can be effective in improving current deficits in medication documentation during emergency department visits.
Young D. Am J Health Syst Pharm. 2005;62:1340-1342.
This article summarizes comments made at the second meeting of the Committee on Identifying and Preventing Medication Errors. Topics covered include teamwork, engaging patients, medication reconciliation, access to information, and hospital design.
Wherry R. Forbes Magazine. June 20, 2005.
This article uses examples from several hospitals to illustrate the behavioral and financial issues involved in implementing information technologies such as electronic health records and order entry systems.
BBC News. August 9, 2005.
This article reports on a prototype electronic wristband that checks medications against a patient's prescription.
Gibbs N, Bower A. Time Magazine. May 1, 2006.
This article takes an unusual look at the problem of medical errors: the perspective of physicians when they or a loved one is the patient. Even physicians well versed in the safety field find that they have relatively little control over the hospital environment and few ways to make their care safer. As the cover piece of Time magazine, this article is likely to generate considerable public discussion.
Grant > Government Resource
Rockville, MD: Agency for Healthcare Research and Quality; June 2008.
This announcement describes the 19 projects funded by the Agency for Healthcare Research and Quality in 2006 that studies the potential of simulation to improve patient safety.
Journal Article > Commentary
Health information technology is a vehicle, not a destination: a conversation with David J. Brailer.
Milstein A. Health Aff (Millwood). 2007;26:w236-w241.
Brailer, the National Coordinator for Health Information Technology ("the IT Czar") from 2004-2006, discusses the fundamental changes needed for the United States to optimize the use of health information technology, including patient ownership of their health care information, universal access to provider performance data, and changes in health care policy.
Urbina I, Nixon R. New York Times. March 30, 2007;National Desk section:1.
This article reports on the inconsistent use of the Department of Defense electronic medical records system and how this has led to medical errors and delays in care for US veterans.
Brown D. Washington Post. April 10, 2007:HE01.
This article describes the Veterans Affairs' universal medical records network and illustrates how use of electronic medical records at VA medical centers supports safe care.
Cooney E. Worcester Telegram & Gazette. January 28, 2008;Living section:E1.
This article discusses an AHRQ-funded program to study information technology tools and their ability to minimize medication errors in a geriatric patient population.
Landro L. Wall Street Journal. January 18, 2010;D5.
This column highlights the work of the Institute for Safe Medication Practices and other groups to raise awareness of medication safety issues, including an initiative to distribute error reports to practitioners, called the National Alert Network for Serious Medication Errors.
Terhune C. Los Angeles Times. August 3, 2012:B1.
This newspaper article reports on an incident during which dozens of hospitals lost access to electronic medical records (EMRs) and discusses risks associated with EMR systems.
Gunderman R. The Atlantic. June 5, 2013.
This magazine article highlights the drawbacks of amassing information in electronic medical records, in that it may negatively influence real communication or clinicians' genuine understanding of the patient.
Freudenheim M. New York Times. December 13, 2010:3B.
This article reports on a committee created by the Institute of Medicine to analyze the potential impact of electronic medical records (EMR) on costs and quality of care.
Landro L. Wall Street Journal. June 7, 2011:D3.
Hamill SD. Pittsburgh Post-Gazette. July 10, 2011:A6.
This newspaper article reports how a missed test result alert led to a disease-free transplant patient being infected with hepatitis.
Landro L. Wall Street Journal. June 9, 2014.
As they become more prevalent, electronic medical records (EMRs) are being used to improve safety in increasingly creative ways. This newspaper article reports on efforts to engage patients in reviewing their medication lists by providing them with access to EMR systems in order to detect and correct discrepancies in data.
Rowland C. Boston Globe. July 20, 2014.
Government incentives have led to rapid development and adoption of electronic health records (EHRs). This newspaper article examines some of the unintended consequences of implementing electronic systems that have not been fully optimized for use in the health care environment, such as serious adverse events and medication errors. Moreover, failure to mandate reporting of EHR-related errors hinders developing strategies to improve them. Although clinicians want to avoid returning to paper records, they find current electronic systems inadequate, difficult to use, and nonintuitive.