Narrow Results Clear All
- Communication between Providers 10
- Culture of Safety 8
- Education and Training 14
- Error Reporting and Analysis 22
- Human Factors Engineering 17
- Legal and Policy Approaches 27
- Logistical Approaches 5
- Policies and Operations 1
- Quality Improvement Strategies 25
- Specialization of Care 1
- Teamwork 1
- Clinical Information Systems 5
- Transparency and Accountability 2
- Device-related Complications 14
- Diagnostic Errors 18
- Discontinuities, Gaps, and Hand-Off Problems 5
- Failure to rescue 1
- Identification Errors 1
- Interruptions and distractions 1
- Medical Complications 18
- Medication Errors/Preventable Adverse Drug Events 30
- MRI safety 1
- Nonsurgical Procedural Complications 3
- Psychological and Social Complications 3
- Second victims 1
- Surgical Complications 9
- Allied Health Services 1
- Internal Medicine
- Pediatrics 6
- Nursing 8
- Pharmacy 8
- Family Members and Caregivers 4
- Health Care Executives and Administrators 36
Health Care Providers
- Nurses 4
- Non-Health Care Professionals 15
- Patients 48
Search results for "Newspaper/Magazine Article"
Palmer J. Patient Saf Qual Healthc. May/June 2019.
Organizations must learn from adverse events to prevent similar incidents. Reporting on lessons to be learned from the cascade of failures connected with the preventable death of a patient during an acute asthma attack at the door of a hospital emergency department, this magazine article outlines the importance of effective signage, appropriate security staff placement, and acceptance of the responsibility for failure.
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.
Schulte F, Lucas E, Mahr J. Kaiser Health News and Chicago Tribune. September 5, 2018.
Sepsis is a serious condition that can be fatal if it is not promptly diagnosed and treated. This news article reports on systemic factors in nursing homes such as poor staffing and communication with families that contribute to unmanaged pressure ulcers and sepsis that result in hospital admissions and death. A WebM&M commentary discussed a case involving a patient who had a pressure ulcer and sepsis in long-term care.
O'Loughlin E. New York Times. April 30, 2018.
Large-scale adverse events should lead to system examination and improvement. This newspaper article reports on misread cervical cancer tests that resulted in 208 women receiving false negative results over a 4-year period from a publicly funded smear test program in Ireland and the government inquiry launched in response to this large-scale failure.
Quick Safety. October 16, 2017;(37):1-3.
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.
Howard J. CNN. October 31, 2016.
Although genetic testing can provide proactive assessment for disease, it can also result in unnecessary care. This news article reports on the unexpected death of a child and how the family experienced psychological harm and received unnecessary care due to misdiagnosis related to false positive test results for long QT syndrome.
Sun LH. The Washington Post. October 13, 2016.
Medical devices can contribute to the spread of health care–associated infections. This news article discusses a government report that raises concerns that patients may have been exposed to a deadly bacterial infection related to an essential piece of equipment used in cardiac surgery worldwide. The resulting infection can be difficult to diagnosis as symptoms may remain dormant for months after the initial exposure.
CDC Vital Signs. August 23, 2016.
ISMP Medication Safety Alert! Acute Care Edition. July 14, 2016;21:1-6.
Patients and clinicians can make medication administration mistakes when new drug delivery mechanisms are introduced. This newsletter article reviews common errors associated with the use of inhalers and offers recommendations for patients, nurses, respiratory therapists, pharmacists, and health care organizations to educate patients on the use of these medications.
Shell ER. Sci Am. 2015;313(5):28-29.
ISMP Canada. August 26, 2015;15:1-4.
Checklists are cognitive aids that help clinicians remember important steps to ensure safe practice. In response to an incident involving a chemotherapy administration error as a result of utilizing the incorrect infusion pump, this newsletter article discusses the development of a point-of-care checklist to assist in use of infusion pumps to improve safety.
ISMP Medication Safety Alert! Acute Care Edition. June 18, 2015;20:1:5.
Brown E, Lin RG II R, Xia R. Los Angeles Times. January 26, 2015.
In light of the recent outbreak of measles in California, this newspaper article reports on how lack of familiarity with measles among clinicians can contribute to diagnostic errors and spread of the disease.
Dunklin R, Thompson S. Dallas Morning News. December 6, 2014.
This news article reports on the widely publicized delayed diagnosis of Ebola at a Dallas hospital and reveals previously undisclosed details from the emergency room physician who misdiagnosed the patient when he first presented, including information and communication gaps that may have contributed to the failure.
Carville O. The Star. November 14, 2014.
This news article reports on a case involving a patient who was misdiagnosed with terminal cancer and touches on the psychological impact of diagnostic error on the patient and his family. The potential causes of the mistake include laboratory sample confusion and misinterpretation of biopsy results.
Loftis RL. Dallas Morning News. October 5, 2014.
Guidelines and rules are developed to help augment safety, but they cannot guarantee it. This news article explores the potential causes for a missed diagnosis of Ebola despite screening procedures for the virus, including weaknesses in an electronic health record system, complacency, and poor communication.
ISMP Medication Safety Alert! Acute Care Edition. July 17, 2014;19:1-4.
To illustrate hazards associated with dispensing more than one dose of certain medications, this newsletter article describes an incident involving an accidental overdose of self-administered oral chemotherapy which resulted in a patient's death. Recommendations to reduce the potential for errors include ensuring labels conform to FDA labeling practices, dispensing only single doses, and providing medication counseling and written instructions for patients.
ISMP Medication Safety Alert! Acute Care Edition. May 22, 2014;19:1-2.
Errors occur frequently in vaccine administration when packaging instructions for diluents are unclear. This newsletter article offers recommendations for manufacturers and practitioners to reduce risks related to vaccines.
Catalanello R. The Times-Picayune. April 15, 2014.