Narrow Results Clear All
- Communication Improvement 1
- Culture of Safety 3
- Education and Training 4
- Error Reporting and Analysis 4
- Human Factors Engineering 3
- Legal and Policy Approaches
- Quality Improvement Strategies 2
- Technologic Approaches 2
- Discontinuities, Gaps, and Hand-Off Problems 3
- Drug shortages 3
- Medical Complications 1
- Medication Errors/Preventable Adverse Drug Events 13
- Overtreatment 1
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Cases & Commentaries
- Spotlight Case
- Web M&M
Sumant Ranji, MD; April 2008
A woman with symptoms of sinusitis was given 2 different courses of broad-spectrum antibiotics, neither of which improved her symptoms. Hospitalized for autoimmune hemolysis (presumably from the antibiotic), the patient suffered multiorgan failure and septic shock, and died.
Perspectives on Safety > Perspective
Organizational Change in the Face of Highly Public Errors—I. The Dana-Farber Cancer Institute Experience
with commentary by James B. Conway; Saul N. Weingart, MD, PhD, Errors in the Media and Organizational Change, May 2005
A decade ago, two tragic medical errors rocked one of the world’s great cancer hospitals, Dana-Farber Cancer Institute (DFCI) in Boston, to its core. The errors led to considerable soul searching and, ultimately, a major change in institutional practices a...
Journal Article > Study
Stebbing C, Kaushal R, Bates DW. Pediatrics. 2006;117:1907-1914.
This study analyzed newspaper coverage of pediatric medication errors and adverse drug events in five countries to demonstrate increased interest in the topic over the past decade. Investigators examined the number of articles and the types of events covered and assessed the overall themes presented and framed by the media. The majority of articles published covered patient incidents followed by policy and then research in decreasing order of frequency. Despite the occasional occurrence of sensational reporting on errors, more than 70% of articles that were deemed to be negatively associated with patient safety were covered in a neutral manner.
Journal Article > Commentary
Dekker S. J Law Med Ethics. 2007;35:463-470.
The author analyzes one Swedish medication error incident that resulted in criminal charges against the nurse involved and discusses how the media contorted the assignment of blame for the failure.
ISMP Medication Safety Alert! Acute Care Edition. February 28, 2008;13:1-2.
This article contextualizes a recent news series on medication errors in community pharmacies, identifies important causes of errors not described in the series, and offers a broader perspective on the factors involved in pharmacy errors.
ISMP Medication Safety Alert! Acute Care Edition. March 27, 2008;13:1-2.
Commenting on a recent news segment, this article calls attention to additional human factors and system failures that may have contributed to a highly publicized medication error.
Willams B. The Record. March 10, 2012.
Exploring how drug shortages affect patients, this news piece describes one cancer patient's efforts to acquire the chemotherapeutic agent that is prolonging his life.
LaGrone K. WPTV.com. April 30, 2012.
This news piece discusses pharmacy medication dispensing errors and describes how patients can help prevent them.
Gupta S. CNN. July 23, 2012.
This news video reports on how drug shortages affect patients and describes US Food and Drug Administration (FDA) efforts to address the issue.
Kane J. PBS NewsHour. October 23, 2012.
This video reveals how checklists can help patients and their families ensure safety during hospital care.
Glass I, Cole S. This American Life. WBEZ Chicago. September 20, 2013.
Grant M. AARP The Magazine. September/October 2010;53:48-51,90-91.
Tomsic M. WFAE Charlotte. National Public Radio. March 21–23, 2013.
This news series reports on the drug shortage problem, its impact on providers and patients, how it began, and concerns that wholesale companies are making it worse.
Eisler P, Hansen B. USA Today. August 20, 2013.
This newspaper article reports on physicians with records of misconduct and how poor oversight for monitoring and discipline allows them to continue practicing medicine.
Jones R. WXYZ. November 13, 2013.
This news piece reports on risks associated with medication delivery in nursing homes and reveals several incidents that resulted in significant patient harm.
Journal Article > Review
Fox ER, Sweet BV, Jensen V. Mayo Clin Proc. 2014;89:361-373.
Suares W. FOX 25 KOKH-TV. July 30, 2014.
This video news segment reports how incorrect medications can be dispensed from pharmacies, notes a lack of regulation mandating that pharmacy errors are reported, and offers tips for patients to reduce risks.
Pierrotti A. USA Today. August 18, 2014.
Jaffe I, Renincasa R. Morning Edition. National Public Radio. December 8–9, 2014.
Overprescribing of medications is a common problem in nursing homes. This two-part radio segment reports on the inappropriate use of antipsychotic medications as a chemical restraint for patients with dementia. The first part introduces the issue and includes insights from families that have experienced harm due to the practice. The second segment discusses programs that the Centers for Medicare and Medicaid Services has put in place to address the problem through a more patient-centered approach to care and suggests strengthening penalties against organizations that overuse antipsychotics.
Journal Article > Review
Systematic review on the prevalence, frequency and comparative value of adverse events data in social media.
Golder S, Norman G, Loke YK. Br J Clin Pharmacol. 2015;80:878-888.
Medication errors are common in the outpatient setting and frequently lead to emergency department visits and hospital admissions. The growth in social media use potentially provides a way to identify safety hazards quickly. This systematic review sought to examine whether social media could provide unique insights into safety issues compared to standard methods of detecting safety hazards. The included studies searched a variety of social media sites (e.g., Twitter, YouTube, and discussion forums) and found that a large number of adverse events are discussed in real time. Most of these events tended to be mild, such as symptoms or asymptomatic lab test abnormalities. Serious adverse events, those requiring urgent treatment or hospitalization, were relatively underrepresented. Although searching social media may help identify unique safety hazards, the investigators concluded that current evidence is insufficient to determine whether routine analysis of social media is of added benefit to traditional surveillance methods.