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Search results for "Active Errors"

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Journal Article > Study

Liquid medication dosing errors by Hispanic parents: role of health literacy and English proficiency.

Harris LM, Dreyer BP, Mendelsohn AL, et al. Acad Pediatr. 2017;17:403-410.

Correctly dosing liquid medications for children can be challenging for caregivers with limited health literacy. This cross-sectional analysis found that parents with limited English proficiency and health literacy were more likely to make dosing errors with liquid medications. These results affirm the need to redesign medication labels and dosing aids to promote safe use.

Journal Article > Study

Patients and families as teachers: a mixed methods assessment of a collaborative learning model for medical error disclosure and prevention.

Langer T, Martinez W, Browning DM, Varrin P, Sarnoff Lee B, Bell SK. BMJ Qual Saf. 2016;25:615-625.

Health systems struggle with how to effectively involve patients in safety efforts without placing undue responsibility or blame on them. Greater patient–clinician collaboration is particularly important for error disclosure because of the well-documented gaps in clinician and patient perspectives. In this study, investigators developed an intervention to have patients or family members teach error disclosure and prevention to interprofessional clinician learners, including physicians, nurses, and social workers. Their pre–post evaluation showed that the majority of patient and clinician participants reported improved communication and found the intervention valuable. Patient and clinician participation was voluntary. Although these results show promise for involving patients and families as teachers for error disclosure and prevention training, further work is needed to determine whether this approach will be effective among broader health care teams, as opposed to interested clinicians who volunteer. A related editorial discusses the challenges of including patients in safety efforts.

Audiovisual

Family matters: pharmacy mix-ups.

Suares W. FOX 25 KOKH-TV. July 30, 2014.

This video news segment reports how incorrect medications can be dispensed from pharmacies, notes a lack of regulation mandating that pharmacy errors are reported, and offers tips for patients to reduce risks.

Journal Article > Study

Parents' perspective on safety in neonatal intensive care: a mixed-methods study.

Lyndon A, Jacobson CH, Fagan KM, Wisner K, Franck LS. BMJ Qual Saf. 2014; 23:902-909.

This interview, observation, and survey study found that parents of infants in neonatal intensive care units identified three core aspects of safety: physical safety relating to immediate treatment, the effect of care on future development, and emotional safety for infants and family, such as having confidence in caregivers. These results argue for enhancing patient and family engagement in safety in this setting.

Perspectives on Safety > Perspective

Patient Advocacy in Patient Safety: Have Things Changed?

with commentary by Helen Haskell, MA, Patient Advocacy, June 2014

This piece describes the evolution of the patient advocacy movement, including the events that spurred it, resulting reforms, and the impact of online access to medical information.

Journal Article > Study

Parental involvement in the preoperative surgical safety checklist is welcomed by both parents and staff.

Corbally MT, Tierney E. Int J Pediatr. 2014;2014:791490.

Many institutions are attempting to increase patient and family engagement in safety efforts. This report on integrating parents of children undergoing surgery into the completion of the WHO surgical safety checklist provides a helpful example of families being successfully incorporated into an existing safety program.

Journal Article > Study

Structuring patient and family involvement in medical error event disclosure and analysis.

Etchegaray JM, Ottosen MJ, Burress L, et al. Health Aff (Millwood). 2014;33:46-52.

Patient engagement is increasingly recognized as a key element for patient safety. Although patients and family members may provide unique insights into adverse events, they are rarely asked to participate in medical error investigations, such as root cause analyses. Using detailed interviews, this study revealed that clinicians and hospital administrators generally support including patients and family members in these types of activities, but they are not sure how best to do so. A group of patients and health care experts at a national conference explored these findings and felt that patient involvement was desirable, but they identified many concerns and limitations with this approach. A recent AHRQ WebM&M perspective by Dr. Saul Weingart discussed the opportunities for patient engagement in patient safety.

Book/Report

Patient Stories 2013: Time for Change.

Harrow, Middlesex, UK: The Patients Association; 2013.

This publication provides patient and family accounts of incidents involving inadequate care or harm and highlights the need for improvements recommended in a National Health Services report.

Newspaper/Magazine Article

Medical errors leave devastating impact on families, professionals.

Bernhard B. St. Louis Post-Dispatch. May 5, 2013:A10.

This newspaper article relates how medical mistakes affect both patients and clinicians and offers tips for patients and families to prepare for surgery.

Journal Article > Commentary

Disclosing medical mistakes: a communication management plan for physicians.

Petronio S, Torke A, Bosslet G, Isenberg S, Wocial L, Helft PR. Perm J. 2013;17:73-79.

This piece describes a two-step model to help physicians disclose medical errors to patients and families.

Perspectives on Safety > Interview

In Conversation With… Beverley H. Johnson

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.

Audiovisual

It's time to say sorry.

Coombes R. BMJ Podcast. June 1, 2012.

This podcast contains interviews discussing family and professional insights on how support for second victims and meaningful apology can address the emotional impact of medical errors.

Newspaper/Magazine Article

Medical mystery: alcoholism didn’t cause man’s diabetes and cirrhosis.

Boodman SG. Washington Post. June 13, 2011:E1.

This newspaper article reveals how biases and lack of trust in the patient/family perspective may contribute to diagnostic error.

Journal Article > Commentary

Successful remediation of patient safety incidents: a tale of two medication errors.

Helmchen LA, Richards MR, McDonald TB. Health Care Manage Rev. 2011;36:1-10.

This commentary compares two cases of preventable medical errors and suggests disclosure and remediation as tactics to establish post–adverse event trust with families and patients.

Journal Article > Commentary

Preventing sentinel events caused by family members.

Wall Y, Kautz DD. Dimens Crit Care Nurs. 2011;30:25-27.

This commentary discusses errors in patient care caused by family members and suggests that involving patients and families in patient awareness programs can help prevent such incidents.

Book/Report

Talking with Patients and Families about Medical Error: A Guide for Education and Practice.

Truog RD, Browning DM, Johnson JA, Gallagher TH. Baltimore, MD: Johns Hopkins University Press; 2011. ISBN: 0801898048.

This publication provides guidelines for disclosure and reveals tactics for effective communication following medical error.

Perspectives on Safety > Perspective

The Role of the Patient in Improving Patient Safety

with commentary by Rosemary Gibson, MSc, The Patient's Role in Safety, March 2007

Patients have three roles in improving patient safety: helping to ensure their own safety, working with health care organizations to improve safety at the organization and unit level, and advocating as citizens for public reporting and accountability of hospital and health system performance. The following case illustrates how patients can help ensure their own safety.

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