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- Communication Improvement 9
- Education and Training 1
- Error Reporting and Analysis 1
- Legal and Policy Approaches 3
- Logistical Approaches 1
- Quality Improvement Strategies 2
- Specialization of Care 1
- Diagnostic Errors 2
- Discontinuities, Gaps, and Hand-Off Problems
- Fatigue and Sleep Deprivation 1
- Medical Complications 1
- Medication Safety 4
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Cases & Commentaries
- Web M&M
Glenn Flores, MD; April 2006
With no one to interpret for them and pharmacy instructions printed only in English, nonEnglish-speaking parents give their child a 12.5-fold overdose of a medication.
Holt TE. Men's Health. November 3, 2006.
This series includes articles on "doorway diagnosis" (or a doctor's assessment of a patient before an exam begins), anesthesiologists addicted to painkillers, and medical mistakes in the emergency room.
Tools/Toolkit > Toolkit
Massachusetts Coalition for the Prevention of Medical Errors, Betsy Lehman Center for Patient Safety and Medical Error Reduction, Massachusetts Medical Society.
This form can help patients document their prescriptions and other health information prior to visits with health care providers.
Tools/Toolkit > Glossary
Chicago, IL: Consumers Advancing Patient Safety; 2009.
This toolkit includes comprehensive information for patients and families to facilitate safe transitions from hospital to follow-up care.
Journal Article > Commentary
Davis Giardina T, Singh H. JAMA. 2011;306:2502-2503.
This commentary discusses a federal proposal to provide patients with direct access to laboratory test results as a tactic to reduce errors.
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.
Lerner M. Star Tribune. October 11, 2012.
This newspaper article reports on how transition coaches can help improve transfer and discharge communication to prevent readmissions.
Rockville, MD: Agency for Healthcare Research and Quality. September 29, 2010.
This trio of public service announcements promotes safe medication use, informed discharge, and family and friends as advocates in the hospital.
Journal Article > Study
Litchfield IJ, Bentham LM, Lilford RJ, McManus RJ, Greenfield SM. Br J Gen Pract. 2015;65:e133-e140.
Journal Article > Study
The Family Caregiver Activation in Transitions (FCAT) tool: a new measure of family caregiver self-efficacy.
Coleman EA, Ground KL, Maul A. Jt Comm J Qual Patient Saf. 2015;41:502-507.
Efforts to improve patient safety during care transitions have had mixed success, possibly due to failure to effectively engage family and caregivers in the transition process. This study reports on the development and validation of a novel survey instrument that measures family and caregivers' preparation and self-efficacy around supporting patients at the time of hospital discharge.
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.