Narrow Results Clear All
- Communication Improvement 2
- Culture of Safety 2
- Error Reporting and Analysis 5
- Human Factors Engineering 4
- Legal and Policy Approaches 11
- Logistical Approaches 1
- Policies and Operations 1
- Quality Improvement Strategies 2
- Teamwork 1
- Technologic Approaches 2
- Transparency and Accountability 1
- Device-related Complications 1
- Diagnostic Errors 3
- Discontinuities, Gaps, and Hand-Off Problems 2
- Identification Errors 1
- Medical Complications 2
- Medication Safety 4
- Second victims 1
- Surgical Complications 3
- Nursing 3
- Pharmacy 1
Search results for "Newspaper/Magazine Article"
Rein L. Washington Post. August 30, 2019.
Gordon M. Health Shots. National Public Radio. April 10, 2019.
Punitive responses to medical errors persist despite continued efforts to reduce them. This news article reports on an incident involving the mistaken use of a neuromuscular blocking agent that resulted in the death of a patient, the prosecution of the nurse who made the error, and systemic and human factors that contribute to similar events.
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.
Another round of the blame game: a paralyzing criminal indictment that recklessly "overrides" just culture.
ISMP Medication Safety Alert! Acute Care Edition. February 14, 2019;24.
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.
Biel L. ProPublica. October 2, 2018.
This news article reports on systemic weaknesses that enabled a surgeon with poor skills to continue to perform procedures after numerous surgical errors that resulted in patient harm. A past PSNet perspective explored the risk of recurring medicolegal events among providers who have received unsolicited patient complaints, faced disciplinary actions by medical boards, or accumulated malpractice claims.
Flatten M. Washington Examiner. August 18–22, 2014.
Sanghavi D. Boston Globe Magazine. January 27, 2013.
Yasgur BS. Medscape Business of Medicine. December 6, 2012.
Pelczarski KM, Braun PA, Young E. Patient Saf Qual Healthc. Sept/Oct 2010;7:20-22,25-26.
This article describes a wrong-site surgery prevention program and how it was successfully implemented in 30 hospitals.
Failed check system for chemotherapy leads to pharmacist's "no contest" plea for involuntary manslaughter.
ISMP Medication Safety Alert! Acute Care Edition. April 23, 2009;14:1-2.
This article examines a case in which a health care professional faces criminal charges for a medication error. The piece discusses how criminalization of errors in health care could thwart broader efforts to learn from mistakes.
Pear R. New York Times. August 19, 2007.
This article reports on a new Centers for Medicare and Medicaid Services (CMS) rule mandating that Medicare will no longer pay for treating certain preventable errors starting in 2008, including some hospital-acquired infections, decubitus ulcers, and retained foreign bodies. The policy is generating considerable discussion in patient safety circles, with some expressing concerns regarding the economic impact on hospitals and the increased efforts it is likely to create for hospitals to document certain patient problems present at the time of admission.
Zimmerman R. Wall Street Journal. February 6, 2007:A1.
This article reports on a mother's campaign to educate parents about kernicterus and to make bilirubin tests standard for all newborns.
Freeman L. Naples Daily News. January 13, 2007.
This article reports on the progress of the Florida Patient Safety Corporation and its near miss reporting initiative.
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.