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- Communication Improvement
- Culture of Safety
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- Error Reporting and Analysis 2
- Human Factors Engineering 4
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- Logistical Approaches 1
- Quality Improvement Strategies 1
- Technologic Approaches 2
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Patient Safety Primers
This Primer provides an overview of the history and current status of the patient safety field and key definitions and concepts. It links to other Patient Safety Primers that discuss the concepts in more detail.
Journal Article > Study
Rosenstein AH, O'Daniel M. Jt Comm J Qual Patient Saf. 2008;34:464-471.
This survey of clinicians and managers from more than 100 hospitals revealed that unprofessional behavior is common among both physicians and nurses. Respondents strongly agreed that disruptive behavior adversely affects patient safety and the quality of care, and the authors recommend various approaches that hospitals can implement to address communication and behavioral problems. A prior commentary discussed system-level solutions to addressing unprofessional behavior, and guidelines have been formulated to identify and address such issues. The concept of just culture has been proposed in order to maintain individual accountability for unsafe behaviors, while acknowledging that most errors occur as a result of system flaws.
No more blame & shame: developing event-reporting systems may go a long way to reducing patient care errors in EMS.
Rajasekaran K, Fairbanks RJ, Shah MN. EMS Mag. 2008 Sep;37:61-67.
This article describes how applying a just culture and systems approach to adverse events may help change the "blame-and-shame" mentality in emergency medical service provision.
Journal Article > Commentary
Hamlin L. AORN J. 2009;90:495-498.
Audiovisual > Audiovisual Presentation
Schiff GD. Institute for Healthcare Improvement; Journal of the American Medical Association. July 20, 2011.
Featuring an discussion with the author of a recent JAMA article, this archived webinar explored systemic causes for delays in test follow-up and offered strategies to address them.