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- Patient Safety Primers 1
- WebM&M Cases 3
- Perspectives on Safety 2
- Review 1
- Study 14
- Audiovisual 2
- Book/Report 10
- Legislation/Regulation 1
- Newspaper/Magazine Article 33
- Special or Theme Issue 2
- Toolkit 3
- Web Resource 9
- Meeting/Conference 1
- Communication Improvement
- Culture of Safety 9
Education and Training
- Students 1
Error Reporting and Analysis
- Error Reporting 17
- Human Factors Engineering 6
- Legal and Policy Approaches 14
- Logistical Approaches 3
- Quality Improvement Strategies 17
- Research Directions 1
- Specialization of Care 5
- Teamwork 6
- Technologic Approaches 16
- Transparency and Accountability 2
- Alert fatigue 1
- Device-related Complications 2
- Diagnostic Errors 8
- Discontinuities, Gaps, and Hand-Off Problems 9
- Failure to rescue 2
- Fatigue and Sleep Deprivation 1
- Identification Errors 4
- Medical Complications 4
- Medication Errors/Preventable Adverse Drug Events 12
- Nonsurgical Procedural Complications 1
- Psychological and Social Complications 12
- Surgical Complications 3
- Medicine 46
- Nursing 1
- Palliative Care 1
- Pharmacy 7
- Family Members and Caregivers 15
- Health Care Executives and Administrators 51
- Health Care Providers 59
Non-Health Care Professionals
- Educators 11
- Media 2
- Australia and New Zealand 6
- Europe 6
- Canada 2
Search results for "Communication Improvement"
Audiovisual > Audiovisual Presentation
Hammond C. BBC News Health Check. July 22, 2015.
The aviation industry represents the gold standard for safety that health care has been working toward. This audio news segment provides insights from psychologists and pilots regarding safety achievements in aviation and how they might be applied in health care to reduce hierarchy, enable raising concerns, and use simulation to design efforts that address human error.
Tools/Toolkit > Multi-use Website
Institute for Healthcare Improvement.
This website provides resources for promoting patient safety during Patient Safety Awareness Week. The 2019 observance will be held March 10–16 and will focus on improving safety in the ambulatory setting. A free webcast on March 13, 2019 between 2:00–3:00 PM (Eastern) will discuss outpatient safety improvement tactics, with Dr. Tejal Gandhi, Dr. Jeff Brady, and Lisa Shilling as featured speakers.
Journal Article > Study
Multiplicity of medication safety terms, definitions and functional meanings: when is enough enough?
Yu KH, Nation RL, Dooley MJ. Qual Saf Health Care. 2005;14:358-363.
The authors reviewed terms and definitions used on medication safety–related Web sites and found a wide variety of definitions in use. They suggest development of standardized definitions to facilitate effective analysis of medication error incidents.
Colino S. Fam Circle. August 2019;132:66,69.
Patients and families can play a role in ensuring care is effective and safe. This news article recommends ways for patients to reduce risk of errors during a hospitalization, including using a patient portal to identify mistakes, asking questions, bringing an advocate, and working with hospitalists as key care partners.
Geneva, Switzerland: World Health Organization; 2019.
Reducing adverse medication events is a worldwide challenge. This collection of technical reports explores key areas of concern that require action at a system level to improve: high-alert medications, polypharmacy, and medication use at care transitions. Each monograph provides an overview of the topic as well as practical improvement approaches for patients, clinicians, and organizations.
Ross C. STAT. May 13, 2019.
Nuisance alarms, interruptions, and insufficient staff availability can hinder effective monitoring and response to acute patient deterioration. This news article reports on how hospital logistics centers are working toward utilizing artificial intelligence to improve clinician response to alarms by proactively identifying hospitalized patients at the highest risk for heart failure to trigger emergency response teams when their condition rapidly declines.
Legislation/Regulation > Colorado Legislation
Pettersen B, Tate J, Tipper K, McKean H. Colorado Senate Bill 19-201.
Communication-and-resolution mechanisms are seen as important approaches to improving transparency and healing after an adverse event. This state bill, referred to as the "Colorado Candor Act," protects conversations between organizations, clinicians, patient, and families from legal discoverability and outlines criteria to guarantee that protection.
Canadian Patient Safety Institute and Health Standards Organization.
This draft 5-year framework aims to guide the activities in Canada to focus action, resources, and policy development on supporting care improvement. The document is structured around five goals: people-centered care, safe care, accessible care, appropriate care, and continuous care. The authors invited Canadian patients, families, clinicians, organization leaders, and policymakers to provide input on the material to ensure its applicability across the country.
Patient Safety Primers
Anyone can find it challenging to understand medical terms, and millions of Americans have trouble understanding and acting upon health information. The mismatch between individuals' health literacy skills and the complexity of health information and health care tasks involved in managing health has implications on patient safety.
Journal Article > Study
Consumers' perspectives on their involvement in recognizing and responding to patient deterioration—developing a model for consumer reporting.
King L, Peacock G, Crotty M, Clark R. Health Expect. 2019;22:385-395.
Journal Article > Study
Patient groups, clinicians and healthcare professionals agree—all test results need to be seen, understood and followed up.
Dahm MR, Georgiou A, Herkes R, et al. Diagnosis (Berl). 2018;5:215-222.
Inadequate test result follow-up places patients at risk of delayed diagnosis, especially in the ambulatory setting. Diverse stakeholders in Australia established an agenda for enhancing test result management, which included better governance, improved use of technology, and consistent patient engagement. A WebM&M commentary explored two incidents where poor test result follow-up led to patient harm.
Lamas D. New York Times. March 27, 2018.
Advance care planning can affect patient safety if the information is unheeded, unavailable, or unread. Reporting on a physician's experience with a patient who nearly received an unwanted intubation due to poor electronic health record data quality and design, this newspaper article describes problems associated with lack of standards for advance care planning documentation and the inability to access advance directives.
Boodman SG. Washington Post. March 26, 2018.
Although providing patients with access to physician notes and test results supports transparency and patient engagement, it can also introduce certain challenges. This newspaper article reports on unintended psychological stresses associated with direct patient access to test results without appropriate contextual information. Improvement strategies include use of graphics, timely patient-centered communication, and scheduling appointments to discuss results. A PSNet perspective explored how patient-facing technologies can empower patients and improve safety.
Perspectives on Safety > Annual Perspective
with commentary by Rachel J. Stern, MD, and Urmimala Sarkar, MD, 2017
Patient engagement in safety has evolved from obscurity to maturity over the past two decades. This Annual Perspective highlights emerging approaches to engaging patients and caregivers in safety efforts, including novel technological innovations, and summarizes the existing evidence on the efficacy of such approaches.
Journal Article > Study
Shiffman S, Cotton H, Jessurun C, Rohay JM, Sembower MA. J Am Pharm Assoc (2003). 2016;56:495-503.
Poor health literacy is associated with the misunderstanding of medication labels, which can lead to adverse drug events. This study sought to assess how adding an acetaminophen icon to the labels of acetaminophen-containing medications affects consumers' ability to avoid unintentional overdose, which is known to cause liver damage. Investigators found that presence of the icon reduced the likelihood of medication errors by 53%, and they concluded that the icon may particularly benefit those with lower health literacy. A past WebM&M commentary discussed a case of liver injury caused by incorrect dosing of acetaminophen.
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.
Rice S. Mod Healthc. 2014;44:16-18, 20.
Language barriers can lead to misunderstandings that increase risks of error. This magazine article highlights the frequent reliance on families, friends, and other nonprofessionals as translators in medical settings and discusses how lack of standards and insufficient reporting of errors related to interpreters, along with challenges to implementing programs, hinder progress in improving communication with non-English speaking patients.
Landro L. Wall Street Journal. June 9, 2014.
As they become more prevalent, electronic medical records (EMRs) are being used to improve safety in increasingly creative ways. This newspaper article reports on efforts to engage patients in reviewing their medication lists by providing them with access to EMR systems in order to detect and correct discrepancies in data.
Yurkiewicz I. Aeon Magazine. January 29, 2014.
Disruptive behavior is a well-known and pervasive issue in health care. Describing disrespectful behaviors that clinicians face, such as sarcasm and intimidation, this magazine article emphasizes how they can hinder effective interactions and communication to reduce patient safety.
Journal Article > Review
Promoting engagement by patients and families to reduce adverse events in acute care settings: a systematic review.
Berger Z, Flickinger TE, Pfoh E, Martinez KA, Dy SM. BMJ Qual Saf. 2014;23:548-555.
Patient engagement is touted as an important tool for detecting adverse events and ensuring safety. This systematic review found that more high-quality evidence is needed to inform practical application of patient engagement programs.