Narrow Results Clear All
- Communication Improvement 4
- Culture of Safety 3
- Education and Training 1
- Error Reporting and Analysis 4
- Human Factors Engineering 3
- Legal and Policy Approaches 4
- Logistical Approaches 1
- Policies and Operations 1
- Quality Improvement Strategies 1
- Technologic Approaches 3
- Transparency and Accountability 2
- Diagnostic Errors 1
- Discontinuities, Gaps, and Hand-Off Problems 4
- Drug shortages 1
- Medical Complications 1
- Medication Safety 5
- Nonsurgical Procedural Complications 1
- Psychological and Social Complications 1
- Surgical Complications 1
- Family Members and Caregivers 1
- Health Care Executives and Administrators
- Health Care Providers 6
- Non-Health Care Professionals 5
Search results for "Newspaper/Magazine Article"
Erich J. EMS World. April 2019;48:26-31.
Air transport service combines risks associated with both aviation and prehospital trauma care. This article discusses the role of human factors in this fast-paced care environment. The author encourages efforts to reduce risks through policy change, purchasing the latest safety equipment, and empowering staff to decline calls when conditions are unsafe.
Simmons-Ritchie D. Penn Live. November 15, 2018.
Nursing home patients are vulnerable to preventable harm due to poor safety culture, insufficient staffing levels, lack of regulation enforcement, and misaligned financial incentives. This news investigation reports on how poor practices resulted in resident harm in Pennsylvania nursing homes and discusses strategies for improvement, such as enhancing investigation processes.
Canadian Medical Protective Association. CMPA Perspective. September 2018;10:8-11.
Frontline leadership should model just culture behaviors to encourage reporting and discussion of error to facilitate improvement. This news article uses a medical administration error to examine whether human error, at-risk behavior, or reckless action on the part of a clinician led to the mistake and explores leadership response to the incident to determine accountability in each type of situation.
Porter S. HealthLeaders Media. April 26, 2018.
Overreliance on technology can result in harmful medication mistakes. Reporting on a 10-fold medication overdose that led to the death of a patient with dementia, this news article describes how the hospital changed their processes to improve medication safety, which included restructuring medication safety leadership, modifying the electronic health record to address alert overrides, and enhancing information sharing to support learning and transparency.
Bartolone P. Kaiser Health News. March 16, 2018.
Drug shortages may require clinicians, pharmacists, and hospitals to divert from standard processes to address gaps. This news article reports how reduced opioid production as an approach to address the opioid crisis has led to shortages and subsequent patient harm, such as insufficient pain management for surgical, cancer, and trauma patients.
Hamilton WL. Patient Saf Qual Healthc. July 31, 2017.
Miscommunication during care transitions can contribute to medical errors. This article discusses how handoff communication tools can help to improve reliability of information transfer associated with anesthesia practice. The authors emphasize the importance of standardizing the process of perioperative data collection.
Rau J. Kaiser Health News. July 6, 2017.
System failures contribute to recurring problems in health care environments. This news article spotlights how lack of follow-up or action related to inspection reports that have uncovered factors in long-term care facilities that contribute to inadequate care can enable poorly performing nursing homes to remain in operation.
Thew J. HealthLeaders Media. June 14, 2017.
ISMP Medication Safety Alert! Acute Care Edition. May 18, 2017;22:1-4.
Verbal orders are known to increase risk of error in care. This newsletter article summarizes survey results that sought to characterize current verbal order behaviors. Notably, practices to improve the reliability of verbal orders such as read backs were not optimally integrated in medication processes. The article includes recommendations for organizations, individuals, and teams to improve the safety of verbal orders.
Shryock T. Med Econ. December 5, 2016.
Computerized decision support and advanced computing are being used to augment various processes in health care, such as medication ordering and diagnosis. This magazine article reports on the accuracy of these systems and the potential role of artificial intelligence in supporting diagnostic decision making.
Khullar D. New York Times. March 17, 2016.
Preventing readmissions after hospital discharge is a national policy priority. This newspaper article discusses how poor communication between hospital-based and outpatient physicians, lack of involvement of the frontline care team in the discharge process, and production pressures can diminish the safety of discharge. The piece also describes strategies to enhance transitions and reduce readmission rates.
Beaulieu-Volk D. Med Econ. 2014;91:52-55.
Apology laws have been explored as a tactic to encourage conversations between patients and clinicians involved in errors, and many states have instituted laws that protect certain statements regarding disclosure from being used in court. This article describes efforts to improve error disclosure and transparency, such as policies to disclose, apologize, and offer compensation to patients who experience adverse events.
Jaffe E. Fast Company. November 11, 2013.
This article reports on a British initiative that studied health care processes for the purpose of designing devices to prevent medical errors.
PA-PSRS Patient Saf Advis. September 2011;8:85-93.
Analyzing reports of medication errors in ambulatory surgery centers, this article discusses common error types and provides suggestions to prevent such events and prioritize improvement efforts.
ISMP Medication Safety Alert! Acute Care Edition. September 21, 2006;11:1-2.
This second part of this series discusses the three types of behavior involved in error—human error, at-risk behavior, and reckless behavior—including causes of each and appropriate responses.
Wahlberg D. Wisconsin State Journal. July 22, 2006:A1.
This article reports on a federal warning issued to a hospital after a medication error led to the death of a 16-year-old girl.