Narrow Results Clear All
Approach to Improving Safety
Safety Target
Search results for "Active Errors"
- Active Errors
- Benchmarking
Download Citation File:
- View: Basic | Expanded
- Sort: Best Match | Most Recent
Journal Article > Study
Standardization of compounded oral liquids for pediatric patients in Michigan.
Engels MJ, Ciarkowski SL, Rood J, et al. Am J Health Syst Pharm. 2016;73:981-990.
When pharmacists make up an individually prepared solution of liquid medication (a process known as compounding) for a pediatric patient, there is a risk for dosing error. This pre–post study demonstrated that implementing a standardized protocol for liquid medication compounding for children was well-received and widely adopted by pharmacists.
Book/Report
Antibiotic Stewardship in Acute Care: A Practical Playbook.
National Quality Partners. Washington, DC: National Quality Forum; 2016.
Antimicrobial stewardship has been promoted as a strategy to improve patient safety by reducing overuse of antibiotics to prevent hospital-acquired infections. This report draws from the experience of existing programs to summarize practical strategies for implementing initiatives. Core elements include engaging leadership, monitoring effectiveness, and reporting benchmarks.
Book/Report
Malpractice Risks in Communication Failures: 2015 Annual Benchmarking Report.
Cambridge, MA: CRICO Strategies; 2016.
Communication failures are known to contribute to medical errors. Analyzing more than 7000 cases in which communication breakdowns led to patient harm, this report explores selected specialties where such failures occur and discusses opportunities to improve information sharing among health care providers.
Book/Report
National Safety Standards for Invasive Procedures (NatSSIPs).
NHS England Patient Safety Domain, National Safety Standards for Invasive Procedures Group. London, UK: National Health Service; 2015.
Patients face risks when undergoing invasive procedures. This report provides recommendations developed by multidisciplinary consensus and outlines how organizations can implement the standards to improve safety of invasive procedures.
Book/Report
2014 Annual Benchmarking Report: Malpractice Risks in the Diagnostic Process.
Hoffman J, ed. Cambridge, MA: CRICO Strategies; 2014.
This analysis of more than 4700 diagnosis-related malpractice claims found that most errors occur in the ambulatory setting, involve lapses in clinical judgement, and result in missed diagnosis of cancer. The authors use the data to explore cognitive and process failures that contributed to diagnostic errors.
Journal Article > Commentary
The Helsinki Declaration on Patient Safety in Anaesthesiology: the past, present and future.
Mellin-Olsen J, Staender S. Curr Opin Anaesthesiol. 2014;27:630-634.
Examining anesthesia safety in Europe following the recommendations outlined in the 2010 Helsinki Declaration, this review describes how checklists and an implementation toolkit contributed to progress and suggests areas requiring further work to achieve the document's goals.
Newspaper/Magazine Article
Still outside the bull's eye: 2014–2015 Targeted Medication Safety Best Practices.
ISMP Medication Safety Alert! Acute Care Edition. March 27, 2014;19:1-5.
This newsletter article reports results of a survey exploring hospital adherence to medication safety best practices meant to address persistent causes of harm. The investigation found poor adoption of safe practices related to oral methotrexate administration and measuring patient weight.
Book/Report
Patient Safety Authority Annual Reports.
Harrisburg, PA: Patient Safety Authority; April 2017.
This report summarizes progress in patient safety improvement in the past decade and reviews the 2016 activities of the Patient Safety Authority, including an initiative to improve the standardization of their reporting process that resulted in an increase of serious events reported and an effort that reduced health care–associated infections in nursing homes.
Newspaper/Magazine Article
Hospitals collaborate to prevent wrong-site surgery.
Pelczarski KM, Braun PA, Young E. Patient Saf Qual Healthc. Sept/Oct 2010;7:20-22,25-26.
This article describes a wrong-site surgery prevention program and how it was successfully implemented in 30 hospitals.
Book/Report
Annual Benchmarking Report: Malpractice Risks in Surgery.
Cambridge, MA: CRICO/RMF Strategies; 2010.
Analyzing data from 3300 surgical malpractice cases, this report describes errors across the continuum of surgical care.
Cases & Commentaries
EMR Entry Error: Not So Benign
- Web M&M
Ross Koppel, PhD; April 2009
A patient hospitalized with Pneumocystis jiroveci pneumonia and advanced AIDS is given another patient's malignant biopsy results, leading his primary physician to mistakenly recommend hospice care.
Cases & Commentaries
A Mid-Summer Fog
- Web M&M
Clarence H. Braddock III, MD, MPH; November 2008
A woman with diabetes is admitted to a teaching hospital in July. An intern, who received training at a hospital where only paper orders were used, mistakenly chose the wrong form for the insulin order. As a result, the insulin dose was not adjusted for the patient's NPO (nothing by mouth) status, and she became unresponsive.
Perspectives on Safety > Interview
In Conversation with…Sanjay Saint, MD, MPH
Prevention of Urinary Tract Infections: Lessons for Patient Safety, November 2008
Sanjay Saint, MD, MPH, is Professor of Medicine at the University of Michigan and the Ann Arbor VA Medical Center in Ann Arbor, Michigan. Dr. Saint's research has focused on reducing health care–associated infections, with a particular focus on preventing catheter-related urinary tract infections (UTIs). We asked him to speak with us about how research on UTI prevention provides broader lessons for patient safety.
Journal Article > Study
Evaluating physician performance at individualizing care: a pilot study tracking contextual errors in medical decision making.
Weiner SJ, Schwartz A, Yudkowsky R, et al. Med Decis Making. 2007;27:726-734.
This study describes a methodology for measuring physician performance and focuses on the ability to expose forms of contextual error.
Cases & Commentaries
Environmental Safety in the OR
- Web M&M
Darren R. Linkin, MD; Ebbing Lautenbach, MD, MPH, MSCE; February 2004
Infection Control notices an uptick in post-operative wound infections for patients from one OR team. Environmental rounds reveal "sloppy" practices.