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- Communication Improvement 1
- Culture of Safety 1
- Education and Training 2
- Error Reporting and Analysis 2
- Human Factors Engineering 1
- Legal and Policy Approaches
- Logistical Approaches 1
- Quality Improvement Strategies 2
- Diagnostic Errors 3
- Discontinuities, Gaps, and Hand-Off Problems
- Medical Complications 1
- Medication Safety 3
- Surgical Complications 1
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Scathing report on Kaiser kidney program. Transplant delays assailed -- Medicare threatens to end coverage.
Russell S. San Francisco Chronicle. June 24, 2006.
This article reports on a Centers for Medicare & Medicaid Services report that details deficiencies in Kaiser's kidney transplant program.
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.
Dwyer J. New York Times. July 11, 2012:A15.
This newspaper article reports on gaps in communication and a missed sepsis diagnosis that led to a patient's death.
Hartocollis A. New York Times. July 28, 2012.
This newspaper article reports on the missteps that contributed to the death of a young woman after she was hospitalized in an incident reminiscent of Libby Zion.
Kane J. PBS NewsHour. October 23, 2012.
This video reveals how checklists can help patients and their families ensure safety during hospital care.
Flatten M. Washington Examiner. August 18–22, 2014.
Shaw G. Hearing J. July 2014;67:11,14-16.
Gubar S. New York Times. October 30, 2014.
This newspaper article describes how surgical complications, health care–associated infections, and ineffective patient–provider communication contributed to a patient's experience with harm and suggests that transparency around the incident and preoperative patient briefings could have improved the situation.
Aleccia J. Seattle Times. June 18, 2016.
Patients who experience harm while receiving medical care can serve as powerful advocates for patient safety. This news article reports on a patient who became engaged in working to redesign processes to improve patient safety after he became paralyzed from the chest down due to a cascade of communication errors.
Rau J. Washington Post. April 29, 2016.
Transitions in care between inpatient and outpatient settings are an increasing concern for patient safety. Reporting on a fatal medication error that was missed by a patient's pharmacist and home health nurses, this newspaper article discusses various risks associated with hospital-to-home transitions such as insufficient case management and communication.