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Search results for "Active Errors"
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Web Resource > Government Resource
Betsy Lehman Center for Patient Safety and Medical Error Reduction.
Center for Health Information and Analysis.
The Betsy Lehman Center is an independent organization named for Betsy Lehman, the Boston Globe columnist who died due to an inadvertent chemotherapy overdose. The Center works to support a statewide program coordinating health care organization and provider efforts to reduce medical errors, enabling patients to participate in safety improvement, and disseminating information about best practices.
Web Resource > Multi-use Website
State-Wide Initiative to Standardize the Compounding of Oral Liquids in Pediatrics.
Michigan Pharmacists Association.
Children are often prescribed oral liquid medications due to difficulty swallowing tablets or capsules. This Web site provides resources for an initiative to standardize concentrations of pediatric oral liquid drugs to reduce inconsistencies that lead to medication errors.
Web Resource > Multi-use Website
Reducing Avoidable Readmissions Effectively (RARE) Campaign.
Institute for Clinical Systems Improvement, Minnesota Hospital Association, and Stratis Health.
This Web site hosts materials to help hospitals enhance discharge planning, medication management, patient and family engagement, care transition, and communication as elements of a state-wide collaborative to reduce readmissions. The program received a 2013 Eisenberg Award.
Newspaper/Magazine Article
Breakdowns in the medication reconciliation process.
Gao T, Gaunt MJ. PA-PSRS Patient Saf Advis. December 2013;10:125-136.
Analyzing data submitted to the Pennsylvania Patient Safety Reporting System, this piece identifies problems related to the medication reconciliation process and includes methods to address them.
Newspaper/Magazine Article
Oral medications inadvertently given via the intravenous route.
Shah-Mohammadi AR, Gaunt MJ. PA-PSRS Patient Saf Advis. September 2013;10:85-91.
Analyzing data submitted to the Pennsylvania Patient Safety Reporting System, this piece identifies incidents in which liquid oral medications were administered intravenously and recommends prevention strategies.
Newspaper/Magazine Article
Distractions and their impact on patient safety.
Feil M. PA-PSRS Patient Saf Advis. March 2013;10:1-10.
Analyzing data submitted to the Pennsylvania Patient Safety Reporting System, this piece outlines the types of distractions that contribute to medical errors and recommends strategies to mitigate them.
Web Resource > Multi-use Website
Patient Safety.
Minnesota Hospital Association.
This Web site provides access to materials for patient safety improvement efforts in Minnesota, including initiatives to reduce adverse drug events and hospital collaboratives to implement best practices.
Journal Article > Commentary
Should medical malpractice prevention be considered separately or as an integral part of comprehensive health care safety improvement?
Enbom JA. Am J Obstet Gynecol. 2013;208:495-498.
Exploring the relationship between liability payments and patient safety, this commentary recommends that the concepts be combined to inform and drive improvement.
Special or Theme Issue
Handoff Communication Tools.
FIRST Do No Harm. December 2012;1-8.
This newsletter issue highlights initiatives and tools developed to improve handoff communication in Massachusetts.
Newspaper/Magazine Article
Ambulatory surgery facilities: a comprehensive review of medication error reports in Pennsylvania.
PA-PSRS Patient Saf Advis. September 2011;8:85-93.
Analyzing reports of medication errors in ambulatory surgery centers, this article discusses common error types and provides suggestions to prevent such events and prioritize improvement efforts.
Newspaper/Magazine Article
Applying the Universal Protocol to improve patient safety in radiology services.
PA-PSRS Patient Saf Advis. June 2011;8:63-69.
Exploring causes of wrong-site, wrong patient, and wrong procedure errors in radiology, this piece suggests strategies to reduce the incidence of such events.
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
Medication errors in the emergency department: need for pharmacy involvement?
PA-PSRS Patient Saf Advis. March 2011;8:1-7.
This piece reports on the prevalence of medication errors in the emergency department and suggests expanding pharmacy involvement as a strategy to reduce risks.
Newspaper/Magazine Article
Diagnostic error in acute care.
PA-PSRS Patient Saf Advis. 2010;7:76-86.
Analyzing reports of diagnostic errors, this article discusses common causes and provides suggestions for physicians and patients to prevent such events.
Newspaper/Magazine Article
Safeguarding the storage of drug products.
PA-PSRS Patient Saf Advis. June 2010;7:46-51.
This piece characterizes medication storage methods that contribute to adverse drug events and provides suggestions for improvement.
Newspaper/Magazine Article
Medication errors with the dosing of insulin: problems across the continuum.
PA-PSRS Patient Saf Advis. March 2010;7:9-17.
This article analyzed 2685 event reports involving insulin and found that the most common error types were drug omission, wrong-dose, and wrong-drug errors.
Special or Theme Issue
Obstetric Issues.
PA-PSRS Patient Saf Advis. December 2009;6(suppl 1):1-32.
Articles in this supplement draw from labor, delivery, and obstetric safety reports to provide insights for safe practice in obstetrics.
Newspaper/Magazine Article
Neuromuscular blocking agents: reducing associated wrong-drug errors.
PA-PSRS Patient Saf Advis. December 2009;6:109-114.
This article discusses adverse incidents submitted to the Pennsylvania reporting system involving neuromuscular blocking agents and shares strategies to minimize errors with this type of high-alert drug.
Journal Article > Study
Wrong site surgery near misses and actual occurrences.
Blanco M, Clarke JR, Martindell D. AORN J. 2009;90:215-222.
This analysis of wrong-site surgery cases and near misses reported to the Pennsylvania Patient Safety Authority found that many cases involved failure to follow The Joint Commission's Universal Protocol for preventing such errors.
Newspaper/Magazine Article
Beyond the count: preventing the retention of foreign objects.
PA-PSRS Patient Saf Advis. June 2009;6:39-45.
This piece identifies risk factors associated with retention of foreign objects and suggests several tactics to prevent its occurrence.