Narrow Results Clear All
- WebM&M Cases 1
- Perspectives on Safety 3
- Review 1
- Study 17
- Audiovisual 1
- Book/Report 12
- Legislation/Regulation 1
- Newspaper/Magazine Article 7
- Toolkit 2
- Web Resource 9
- Meeting/Conference 2
- Press Release/Announcement 1
- Communication Improvement
- Culture of Safety 2
- Education and Training 23
- Error Reporting and Analysis 9
- Human Factors Engineering 7
- Legal and Policy Approaches 3
- Logistical Approaches 1
- Quality Improvement Strategies 16
- Research Directions 1
- Specialization of Care 4
- Teamwork 1
- Technologic Approaches 8
- Device-related Complications 1
- Diagnostic Errors 1
- Discontinuities, Gaps, and Hand-Off Problems 7
- Identification Errors 2
- Medical Complications 2
- Medication Errors/Preventable Adverse Drug Events 13
- Nonsurgical Procedural Complications 1
- Surgical Complications 1
- Medicine 27
- Nursing 1
- Pharmacy 13
- Family Members and Caregivers 2
- Health Care Executives and Administrators
Health Care Providers
- Nurses 2
Non-Health Care Professionals
- Educators 15
- Patients 16
- Europe 3
- United States of America 48
Search results for ""
Cases & Commentaries
- Web M&M
Dean Schillinger, MD; March 2004
A misunderstanding of instructions on how to administer medication leads to an infant choking on a syringe cap.
Perspectives on Safety > Perspective
with commentary by Nancy C. Elder, MD, MSPH, Outpatient Safety, May 2006
Dr. Jones was sure he had increased Mr. H's cholesterol-lowering medication to 80 mg 6 months ago, but, at his visit today, his pill bottle still says 40 mg. In reviewing Ms. B's chart in preparation for performing a well-woman examination, Dr. Smith find...
Perspectives on Safety > Perspective
with commentary by Michael S. Wolf, PhD, MPH; Stacy Cooper Bailey, MPH, Health Literacy and Safety, February-March 2009
Clear health communication is increasingly recognized as essential for promoting patient safety. Yet according to a recent Joint Commission report, What Did the Doctor Say? Improving Health Literacy to Protect Patient Safety, communication problems among health care providers, patients, and families are common and a leading root cause of adverse outcomes. Addressing health literacy—the capacity of individuals to obtain, process, and understand basic health information and services needed to make appropriate health decisions—has become a primary objective for many health systems in order to protect patients from harm.
Perspectives on Safety > Interview
Health Literacy and Safety, February-March 2009
Dean Schillinger, MD, is a Professor of Medicine at University of California, San Francisco, Director of the UCSF Center for Vulnerable Populations, and Chief of the California Diabetes Prevention and Control Program. His role as a practicing clinician at a safety net hospital (San Francisco General Hospital) has put him in a unique position to pursue influential and relevant research related to health literacy and improving care for vulnerable populations.
Briefings on Patient Safety. June 2005;6:1-3.
This article describes the Partnering for Patient Empowerment Through Community Awareness program, a model for utilizing libraries to educate consumers about their role in patient safety. Pointers for launching similar programs in other communities are provided.
Journal Article > Commentary
The Risk Management Reporter. June 2005;24:1,3-7.
This commentary provides a definition of patient-centered care, lists potential impediments to implementation, and highlights several successful initiatives in acute care hospitals.
Tools/Toolkit > Multi-use Website
Johns Hopkins University, Department of Anesthesiology & Critical Care Medicine.
This Web site provides information on the multidisciplinary safety team at Johns Hopkins University, including research projects, presentations, and useful tools for patients, families, and practitioners.
Wu HW, Nishimi RY, Page-Lopez CM, Kizer KW. Washington, DC: National Quality Forum; 2005.
In the 2003 report Safe Practices for Better Healthcare, the National Quality Forum (NQF) recommended 30 practices, one of which emphasized improved communication in the informed consent process. This report builds on that safe practice endorsement by summarizing strategies for rapid and widespread adoption. The report describes experiences from four hospitals that successfully implemented the practice and discusses common barriers and solutions involved. Recommendations are provided to guide health care organizations still striving to meet the requirement for an effective informed consent process.
Journal Article > Study
Hibbard JH, Peters E, Slovic P, Tusler M. Med Care Res Rev. 2005;62:601-616.
This AHRQ-funded study conducted interviews with nearly 200 participants to assess their likelihood of engaging in preventive actions to avoid medical errors. The 14 preventive actions discussed were from a list generated by an AHRQ publication as well as from focus groups conducted by CMS. The investigators discovered significant variability in both the perceived effectiveness of a given action and the likelihood of taking that action. The authors advocate for greater attention to educating patients about their own safety, along with broader safety issues.
Franklin D. New York Times. October 25, 2005:F1.
This article discusses an important health literacy and medication safety concern: the absence of standardization of colored warning labels applied to prescription bottles. Inconsistent messages, icons, and colors may cause confusion for consumers.
Rockville, MD: Agency for Healthcare Research and Quality. March 6, 2006.
This podcast features an interview with AHRQ Director Carolyn Clancy on educating clinicians and patients and families about patient safety.
Journal Article > Commentary
Alton M, Mericle J, Brandon D. Adv Neonatal Care. 2006;6:112-119.
The authors describe the implementation of a safety program to instill a culture of safety following a high-profile sentinel event.
ISMP Medication Safety Alert! Acute Care Edition. June 1, 2006:1-2.
This article discusses one hospital's initiative to empower patients and their families to call for a rapid response team if they feel it is necessary.
Journal Article > Review
Warner A, Menachemi N, Brooks RG. Hosp Pharm. 2006;41:542-551.
This literature review examined the assumption that low levels of health literacy contribute to medical errors. The authors summarize the findings from past studies that addressed health literacy in relationship to medication errors and health outcomes before drawing several conclusions. They report that studies do associate low literacy levels with adverse health outcomes, but further investigation is required to better understand the link between literacy and medication errors. A past report from the Institute of Medicine examined the field of health literacy broadly and discussed strategies to drive improvement efforts.
Committee on Identifying and Preventing Medication Errors, Aspden P, Wolcott J, Bootman JL, Cronenwett LR, eds. Washington, DC: The National Academies Press; 2007.
A major report by the Institute of Medicine (IOM) on medication errors suggests that, despite all the progress in patient safety since To Err is Human, medication errors remain extremely common, and the health care system can do much more to prevent them. Among the startling statistics from this report: more than 1.5 million Americans are injured every year in American hospitals, and the average hospitalized patient experiences at least one medication error each day. The report emphasizes actions that health care systems, providers, funders, and regulators can take to improve medication safety. These actions include having all US prescriptions written and dispensed electronically by 2010, more widespread use of medication reconciliation, and additional research on drug errors and how to prevent them. Importantly, the report also emphasizes actions that patients can take to prevent medication errors, such as maintaining active medication lists and bringing their medications to appointments. Support for the IOM report came from the Centers for Medicare & Medicaid Services.
Kaiser Family Foundation, Agency for Healthcare Research and Quality; September 2006.
This survey follows up on a prior study from 2004, asking patients about their perceptions of health care quality and medical errors. The study found minimal change since 2004 in overall impression of US health care quality, with approximately half of respondents stating they are "dissatisfied" with quality, particularly with coordination of care. More patients are aware of information comparing the quality of hospitals, health care plans, or providers, but only a small minority report using this information to make health care decisions. A large proportion of patients reported taking recommended actions to improve safety, such as bringing a list of their medications to appointments or following up on test or procedure results. As found in other studies, survey respondents overwhelmingly expressed support for full, mandatory disclosure of all preventable errors, and two-thirds felt errors should be publicly reported.
Kapadia R. Smart Money. October 2006;15:112-114.
This article provides tips for consumers to help keep their hospital care as safe and hassle-free as possible.
Foubister V. Quality Matters. November/December 2006.
This article describes the concept of health literacy and efforts to measure and improve health literacy in the United States.
St. Paul, MN: Minnesota Department of Health; January 2009.
This report provides background on the Minnesota Never Events reporting initiative, tips for patients on how to receive the safest care possible, and a table of events reported by all hospitals in the state.
Journal Article > Commentary
Polzien G. Home Healthc Nurse. 2007;25:59-62.
The author summarizes suggestions from the 2006 Institute of Medicine report on medication error to help patients avoid medication errors.