Narrow Results Clear All
- Communication between Providers
- Culture of Safety 4
- Education and Training 6
- Error Reporting and Analysis 9
- Human Factors Engineering 11
- Legal and Policy Approaches 5
- Logistical Approaches 2
- Quality Improvement Strategies 7
- Teamwork 5
- Clinical Information Systems 3
- Device-related Complications 4
- Diagnostic Errors 6
- Discontinuities, Gaps, and Hand-Off Problems 9
- Identification Errors 13
- Medication Errors/Preventable Adverse Drug Events 13
- Nonsurgical Procedural Complications 2
- Psychological and Social Complications 3
- Surgical Complications 16
- Internal Medicine 10
- Nursing 1
- Pharmacy 5
- Health Care Executives and Administrators 22
Health Care Providers
- Nurses 4
- Non-Health Care Professionals 7
- Patients 19
Search results for "Newspaper/Magazine Article"
Cierniak KH, Gaunt MJ, Grissinger M. PA-PSRS. Patient Saf Advis. 2018;15(4).
The operating room environment harbors particular patient safety hazards. Drawing from 1137 perioperative medication error reports submitted over a 1-year period, this analysis found that more than half of the recorded incidents reached the patient and the majority of those stemmed from communication breakdowns during transitions or handoffs. The authors provide recommendations to reduce risks of error, including using barcode medication administration, standardizing handoff procedures, and stocking prefilled syringes.
Howley EK. US News & World Report. September 5, 2018.
Communication failures in health care routinely challenge patient safety. This news article describes characteristics of the hospital environment that affect nurse–physician relationships such as bullying, production pressure, and care complexity. Clarifying team roles and interdisciplinary activities can improve communication in the care environment. Patients are encouraged to have advocates with them to help prevent and address misunderstandings.
R3 Report. June 25, 2018;7:1-2.
Meyer TA, McAllister RK. Pharmacy Practice News. March 19, 2018.
Perioperative adverse drug events are common and understudied. Reporting on the complexity of medication administration during surgery, this news article reviews strategies to reduce risks of surgical adverse drug events. Specific tactics discussed include proactive problem identification, medication reconciliation, high-alert medication process vigilance, verbal order reduction, and information technology optimization.
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.
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.
ISMP Medication Safety Alert! Acute Care Edition. December 1, 2016;21:1-3.
Accidental administration of irrigation solutions are a wrong-route error that can result in harm. This newsletter article reviews factors that contribute to these incidents in the operating room, such as unlabeled solutions, look-alike labeling, and line connection issues. Recommendations to reduce risks include communicating during transitions, safe storage, and immediate labeling.
ED Manag. June 2016;28:S1-S4.
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.
Offri D. New York Times. October 8, 2015.
This news article offers insights from a physician about the complexities around establishing a diagnosis in frontline practice and the recent IOM report recommendation to improve reimbursement systems as a way to encourage physicians to spend more time on the cognitive component of forming a diagnosis rather than simply ordering imaging tests.
Clarke JR. PA-PSRS Patient Saf Advis. 2015;12:19-27.
Wrong-site surgeries are considered never events by the National Quality Forum and sentinel events by The Joint Commission. Drawing from data submitted to the Pennsylvania Patient Safety Authority, this article analyzes 83 wrong-site extremity procedures in orthopedic surgery reported over 9 years and recommends site marking and time outs as strategies to prevent these incidents.
The high cost of low morale in the clinical laboratory: how workplace environment impacts patient safety.
Barker T, Noguez J. Clinical Laboratory News. January 1, 2015.
Njoroge S, Nichols JH. Clinical Laboratory News. July 2014.
Highlighting how the disconnect between clinicians conducting point-of-care testing as a patient care action and laboratory staff performing the analysis of the test can affect detection of errors, this news article suggests quality control strategies to address risks related to monitoring, testing, and device use.
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.
Gao T, Gaunt MJ. PA-PSRS Patient Saf Advis. December 2013;10:125-136.
Analyzing data submitted to the Pennsylvania Patient Safety Reporting System, this piece identifies problems related to the medication reconciliation process and includes methods to address them.
Diamond F. Manag Care. July 2013;22:30-32.
Agency for Healthcare Research and Quality. Research Activities. May 2013:1, 3-4.
This newsletter article describes the development of the Medications at Transitions and Clinical Handoffs (MATCH) toolkit and relates one hospital's experience implementing it.
Boodman SG. Washington Post. March 4, 2013.
This newspaper article reports on how anger management courses can address physicians' disruptive behavior and improve their coping and communication skills.
Stempniak M. Hosp Health Netw. 2012 Oct;86:8 p following 40.
Eban K. Self Magazine. November 2011.
This magazine article reports on cases in which outsourcing the interpretation of radiology tests contributed to patient harm.