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- Communication Improvement 2
- Culture of Safety 1
- Education and Training 1
- Error Reporting and Analysis 6
- Logistical Approaches 1
- Quality Improvement Strategies 2
- Transparency and Accountability 2
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Perspectives on Safety > Interview
Engaging the Patient and Family in Safety, February 2013
Beverley Johnson is President and Chief Executive Officer of the Institute for Patient- and Family-Centered Care.
Boodman SG. Washington Post. June 13, 2011:E1.
Journal Article > Study
A patient-initiated voluntary online survey of adverse medical events: the perspective of 696 injured patients and families.
Southwick FS, Cranley NM, Hallisy JA. BMJ Qual Saf. 2015;24:620-629.
This study analyzed data from an internet-based reporting system that enabled patients and families to describe adverse events. Respondents reported missed and delayed diagnoses, treatment errors, procedural complications, health care–associated infections, and adverse drug events. Most participants did not experience prompt error disclosure but instead faced a denial of responsibility and secretive behavior, which they related to subsequent mistrust. To prevent adverse events, patients and family members suggested using systems approaches (such as universal handwashing and other infection control measures), improving care transitions between providers, ensuring supervision of trainees, and partnering with patients and families for shared decision-making. These findings underscore the importance of error disclosure, effective communication, and allowing patients to report adverse events in order to enhance safety.
Journal Article > Commentary
Miller K, Dastoli A. Int J Qual Health Care. 2018;30:654-657.
Medical error affects the lives of patients, families, and members of the care team. Discussing an error that resulted in the death of a young man, this commentary reviews how cognitive bias and misdiagnosis contributed to the incident and the impact of the patient's death on his family, friends, and the physician who made the mistake. The authors highlight the use of autopsy results to identify the error.
Canadian Patient Safety Institute. October 2018.
Park A. Time Magazine. January 24, 2019.
This news article reports on the documentary To Err Is Human, which was produced and directed by the son of patient safety leader Dr. John M. Eisenberg. The film is structured around patient safety advocate Sue Sheridan's experience with diagnostic errors that resulted in harm for both her son and husband. It features a wide range of experts who discuss the impact of error on all involved, the role of culture in facilitating both mistakes and progress, and why continued work in health care safety is needed.
Journal Article > Commentary
Fitzsimons BT, Fitzsimons LL, Sun LR. Pediatrics. 2019;143:e20183458.
Rare diseases pose diagnostic challenges for physicians. This commentary offers insights from parents of a young child who died due to a delayed stroke diagnosis as well as from the patient's neurologist to raise awareness of childhood stroke and discuss the importance of partnership to heal from loss and advocate for improvement.
Cullen A. Uitgeverij van Brug: The Hague, The Netherlands; 2019. ISBN: 9789065232236.
Patient stories offer important insights regarding the impact medical errors have on patients and their families. This book shares the author's experience with medical error and spotlights how lack of transparency in European health care can contribute to avoidable process failures that result in patient harm.