Narrow Results Clear All
- Patient Safety Primers 7
- WebM&M Cases 61
Perspectives on Safety
- Interview 25
- Perspective 18
- Commentary 438
- Review 320
- Study 1783
- Slideset 3
- Book/Report 228
- Legislation/Regulation 19
- Newspaper/Magazine Article 252
- Newsletter/Journal 1
- Special or Theme Issue 37
- Toolkit 8
- Web Resource 172
- Award 3
- Biography 1
- Clinical Guideline 1
- Grant 3
- Meeting/Conference 12
- Press Release/Announcement 20
Communication between Providers
- Sbar 2
- Communication between Providers 178
- Culture of Safety 218
Education and Training
- Simulators 28
- Students 20
Error Reporting and Analysis
- Error Analysis 1553
- Error Reporting 1121
Human Factors Engineering
- Checklists 44
Legal and Policy Approaches
- Regulation 33
- Logistical Approaches 75
- Policies and Operations 18
Quality Improvement Strategies
- Benchmarking 57
- Research Directions 21
- Specialization of Care 43
- Teamwork 82
- Clinical Information Systems 115
- Transparency and Accountability 44
- Alert fatigue 3
- Device-related Complications 128
- Diagnostic Errors 343
- Discontinuities, Gaps, and Hand-Off Problems 181
- Drug shortages 11
- Failure to rescue 12
- Fatigue and Sleep Deprivation 28
- Identification Errors 72
- Inpatient suicide 10
- Interruptions and distractions 39
- Delirium 2
- Medication Errors/Preventable Adverse Drug Events 510
- MRI safety 8
- Nonsurgical Procedural Complications 73
- Overtreatment 19
- Psychological and Social Complications 289
- Second victims 31
- Surgical Complications 445
- Transfusion Complications 22
- Home Care 22
- Operating Room 352
- General Hospitals 819
- Long-Term Care 56
- Outpatient Surgery 39
- Patient Transport 35
- Psychiatric Facilities 33
- Allied Health Services 8
- Dentistry 3
- Anesthesiology 104
- Critical Care 197
- Dermatology 11
- Gynecology 32
- Cardiology 42
- Geriatrics 96
- Hematology 17
- Medical Oncology 117
- Pulmonology 11
- Neurology 28
- Obstetrics 62
- Pediatrics 305
- Primary Care 149
- Radiology 81
- Nursing 146
- Palliative Care 7
- Pharmacy 120
- Family Members and Caregivers 50
Health Care Executives and Administrators
- Nurse Managers 108
- Risk Managers 369
Health Care Providers
- Nurses 184
- Pharmacists 65
- Physicians 597
Non-Health Care Professionals
- Educators 149
- Engineers 47
- Media 8
- Policy Makers 221
- Patients 212
- Africa 11
- China 6
- Australia and New Zealand 147
- Central and South America 5
- United Kingdom 414
- Canada 168
United States of America
United States Federal Government
- Department of Health and Human Services (HHS) 127
- United States Federal Government 207
Search results for "Medicine"
- Error Reporting and Analysis
The Healthcare Commission. London, England: Commission for Healthcare Audit and Inspection; 2006. ISBN: 1845621182.
This report shares findings from an analysis of the state of health care in the United Kingdom. It reveals that one in five complaints received by the Healthcare Commission was safety related and that the UK health system needs to be more consistent in its application of tools and standards to fully promote safety and quality.
Journal Article > Study
A new safety event reporting system improves physician reporting in the surgical intensive care unit.
Schuerer DJ, Nast PA, Harris CB, et al. J Am Coll Surg. 2006;202:881-887.
This Agency for Healthcare Research and Quality (AHRQ)–supported study demonstrated that implementation of a card-based reporting system in place of an existing and underused online one increased reporting rates among both physicians and nurses. Investigators provided education prior to introduction of the new card reporting system as they introduced it, removed it, and reintroduced it to determine the effectiveness. Physician reporting dropped to zero after the card was removed and rose to peak levels after reintroduction. The authors also discuss the differences in the reports themselves, which suggested physicians more frequently report events that caused harm. Given the emphasis on reporting systems, the authors suggest this as an alternative mechanism to encourage reporting from physicians, a group very involved in patient care but infrequently participating in the event reporting process. A past survey study described physician perception of hospital safety and barriers to incident reporting.
Journal Article > Study
Szekendi MK, Sullivan C, Bobb A, et al. Qual Saf Health Care. 2006;15:184-190.
This study demonstrated the effective use of an active surveillance methodology designed to improve on current systems that fail to capture events at the time of occurrence. Investigators evaluated more than 325 medical records that were identified based on electronic triggers to develop their method for reviewing adverse events in real time. The authors discuss the large percentage of preventable adverse events that were discovered along with some of the interventions designed to prevent their recurrence. They also discuss how an active surveillance process would improve on existing hospital-wide efforts to promote patient safety.
Santell JP. Drug Topics (Health-System Edition). May 22, 2006.
This article reports on errors involving neuromuscular blocking agents (NMBAs) that were reported to Medmarx database, what factors contributed to those errors, and what can be done to minimize their occurrence.
Baltimore, MD: Centers for Medicare & Medicaid Services (CMS) Office of Public Affairs; May 18, 2006.
This fact sheet provides information regarding the Centers for Medicare and Medicaid Services' initiative to better understand and minimize never events.
Special or Theme Issue
Med J Aust. 2006;184:S37-S72.
This special issue includes numerous articles reviewing the activities and successes of the patient safety movement outside the United States.
Journal Article > Commentary
Smith KM, Trapskin PJ, Empey PE, Hecht KA, Armitstead JA. Hosp Pharm. 2006;41:428-436.
The authors describe the development and use of an in-house, online reporting system.
Journal Article > Study
Maio V, Hartmann CW, Poston S, Liu-Chen X, Diamond J, Arenson C. Am J Med Qual. 2006;21:162-168.
The research team comparatively examined incidents of potentially inappropriate prescribing for elderly patients at a nursing home and at a general practice. They found that inappropriate prescribing may be prevalent in both settings.
Zaidi K, Curry PD Jr, Becker SC. Pharmaceutical Technology. November 2, 2005;29:102-103.
This article reports on recommendations developed by United States Pharmacopeia (USP) to improve the safety of using medical gas, including revisions to USP monographs.
Meeting/Conference > Canada Meeting/Conference
Canadian Patient Safety Institute. October 8–9, 2019; Sheraton Hotel Newfoundland, St. John's, NL.
This conference will share care improvement experiences of providers, policymakers, and health care executives from the four Atlantic Canadian Provinces. Topics covered will include patient engagement, staff well-being, the role of technology and innovation in health care, and patient safety measurement. Jeffrey Braithwaite is a featured speaker.
Meeting/Conference > United States Meeting/Conference
Institute for Professionalism and Ethical Practice. September 17, 2019; 9:00–11:00 AM (Eastern).
Error disclosure conversations can be difficult for clinicians and patients. This workshop will outline the elements of effective disclosure and apology. Tools, best practices, and scenarios will be used to help participants develop skills to support their effective participation in error disclosure.
Cases & Commentaries
- Web M&M
Andrew P. Olson, MD; September 2019
A woman with acute myeloid leukemia presented to the emergency department (ED) with shortness of breath after receiving chemotherapy. As laboratory test results showed acute kidney injury and suggested tumor lysis syndrome, the patient was started on emergent hemodialysis. She experienced worsening dyspnea and was emergently intubated and transferred to the intensive care unit. There, her blood pressure began to drop, and she died despite aggressive measures. During the code, the laboratory called with positive blood culture results; although blood cultures and broad-spectrum antibiotics had been ordered while the patient was in the ED, the antibiotics were not administered until several hours later. Due to the urgent focus on the patient's oncologic emergency, the diagnosis of sepsis was missed.
Perspectives on Safety > Interview
Patient Safety at 20, September 2019
Dr. Agrawal is president and CEO of the National Quality Forum (NQF). We spoke with him about the National Quality Forum, including its role in quality measurement, patient safety, and improvement.
Rein L. Washington Post. August 30, 2019.
Journal Article > Commentary
Lucey CR, Jones L, Eastburn A. N Engl J Med. 2019;381:793-795.
This commentary discusses an incident involving a medical student with a history of opioid use disorder who relapsed during training and overdosed. The authors summarize the results of the root cause analysis of the incident and recommend structural interventions for medical schools such as personnel assessment for substance abuse when behavior is reported that should trigger that action and curricula for students regarding opioid use disorders in health professionals to minimize stigma and to offer effective actions for support.
ISMP Medication Safety Alert! Acute Care Edition. August 29, 2019;24.
Mistakes in the administration of intravenous (IV) medications can result in patient harm. Analyzing data from 243 health care facilities regarding the quality of IV push practices in the field, this newsletter article reports adoption of practices such as the use of a new syringe and needle for every IV push injection and outlines 10 best practices to consider for improvement, including the routine supply of IV push medications in ready-to-administer containers and reporting to external bodies to enhance learning.
Journal Article > Study
Risk of wrong-patient orders among multiple vs singleton births in the neonatal intensive care units of 2 integrated health care systems.
Adelman JS, Applebaum JR, Southern WN, et al. JAMA Pediatr. 2019 Aug 26; [Epub ahead of print].
A classic study found that the replacing the usual naming convention for newborns ("Babygirl" or "Babyboy") with one incorporating the mother's first name (e.g., "Marysgirl" or "Marysboy") reduced wrong-patient errors. Based on this finding, The Joint Commission issued a National Patient Safety Goal (NPSG) requiring the use of distinct naming systems for newborns. The authors of this study noted that the new standard would still leave multiple-birth infants vulnerable to wrong-patient errors, as most hospitals adopted naming standards that left room for confusion between infants (e.g., twin infants might be named "Marysgirl1" and "Marysgirl2"). Researchers examined the rate of wrong-patient errors in six neonatal intensive care units of two health systems that used the NPSG recommended naming conventions, comparing multiple-birth infants to singleton infants. They measured wrong-patient errors by tracking the rate of orders that were retracted and then immediately reordered for a different patient. The rate of wrong-patient errors was significantly higher among multiple-birth infants, most of which could be explained by intrafamilial errors (e.g., a medication was ordered for one twin when intended for another). The accompanying editorial points out that this study is an important example of carefully assessing the real-world impact of novel policies; in this case, the NPSG likely does protect against wrong-patient errors for singleton infants, but not for multiple-birth infants.
Journal Article > Study
Woodcock T, Liberati EG, Dixon-Woods M. BMJ Qual Saf. 2019 Aug 24; [Epub ahead of print].
The development of accurate and reliable measurements was identified as a major priority for the patient safety field in an influential 2015 report. This mixed-methods study of a large-scale improvement program in the United Kingdom provides important insights into the challenges of measuring safety in real-world settings. In the program, quality improvement teams at each of the nine participating hospitals chose targets and developed metrics with assistance from external mentors. The measurement strategies were reviewed by the study investigators, who also conducted structured interviews with quality improvement team members at each site. Measurement was a challenge for all sites, attributed in large part to frontline staff's lack of experience in data analysis and reliance on homegrown rather than externally validated safety metrics. This manifested in the use of metrics that often were overambitious, not linked to the interventions that were being implemented, or not analyzed in a statistically appropriate fashion. As a result, it was difficult to determine if improvement in the safety targets had been achieved. A previous PSNet interview featured the study's senior author, Mary Dixon-Woods.
Armstrong D. ProPublica. August 23, 2019.
Washington, DC: Department of Veterans Affairs, Office of Inspector General. August 22, 2019. Report No. 19-07429-195.
Hospitalized patient suicide is a sentinel event. This report describes an investigation into a patient suicide incident in the Veterans Affairs health system that found numerous conditions that contributed to the event, such as nonoperational security cameras, ineffective rounding policy, and lack of leadership knowledge of safety practices in mental health units. Recommendations for improvement include staff education, standardization of rounding, and robust oversight of frontline practice.