Narrow Results Clear All
- Study 3
- Slideset 1
- Legislation/Regulation 4
- Newspaper/Magazine Article
- Special or Theme Issue 17
- Toolkit 1
- Web Resource 33
- Award 5
- Grant 1
Communication between Providers
- Sbar 4
- Communication between Providers 164
Culture of Safety
- Just Culture 11
Education and Training
- Simulators 17
- Students 11
Error Reporting and Analysis
- Never Events 12
- Error Reporting 202
Human Factors Engineering
- Checklists 44
Legal and Policy Approaches
- Regulation 57
- Logistical Approaches 73
- Policies and Operations 12
Quality Improvement Strategies
- Benchmarking 16
- Reminders 11
- Specialization of Care 50
- Teamwork 53
- Clinical Information Systems 123
- Transparency and Accountability 20
- Alert fatigue 4
- Device-related Complications 73
- Diagnostic Errors 104
- Discontinuities, Gaps, and Hand-Off Problems 102
- Drug shortages 19
- Failure to rescue 3
- Fatigue and Sleep Deprivation 22
- Identification Errors 52
- Interruptions and distractions 12
- Delirium 1
- Medication Errors/Preventable Adverse Drug Events 284
- MRI safety 4
- Nonsurgical Procedural Complications 24
- Overtreatment 5
- Psychological and Social Complications 79
- Second victims 8
- Surgical Complications 147
- Transfusion Complications 4
- Ambulatory Care 114
- Operating Room 103
- General Hospitals 208
- Long-Term Care 18
- Outpatient Surgery 18
- Patient Transport 8
- Psychiatric Facilities 6
- Allied Health Services 5
- Dentistry 1
- Geriatrics 21
- Obstetrics 24
- Pediatrics 52
- Primary Care 12
- Radiology 21
- Internal Medicine 312
- Nursing 70
- Palliative Care 1
- Pharmacy 204
- Family Members and Caregivers 38
- Health Care Executives and Administrators 639
Health Care Providers
- Nurses 99
- Pharmacists 93
- Physicians 194
Non-Health Care Professionals
- Educators 40
- Engineers 41
- Media 9
- Policy Makers 104
- Patients 556
- Asia 1
- Europe 41
- Canada 13
United States of America
United States Federal Government
- Department of Health and Human Services (HHS) 24
- United States Federal Government 30
Search results for ""
Joseph R, Harry E. Medical Economics. June 27, 2019.
Multitasking can negatively affect cognitive load and diminish safety. This magazine article reports on how multitasking can contribute to surgeon fatigue, burnout, and decreased task completion in the perioperative environment. Checklists to automate workflow and limiting the number of patient charts that can be open at one time can help reduce extraneous cognitive load.
Appleby J, Lucas E. Kaiser Health News. June 21, 2019.
ISMP Medication Safety Alert! Acute Care Edition. June 6, 2019;24.
Butcher L. Managed Care. June 2019;28:37-39.
Inconsistent patient name entry practices in electronic health records can contribute to wrong-patient errors. This magazine article reports on the complex nature of addressing patient-matching discrepancies as an economic, privacy, and technical problem. Improvement strategies include the development and adoption of a national identification program and biometric technology. A WebM&M commentary discussed problems associated with name similarities in the electronic patient record.
Gabler E. New York Times. May 31, 2019.
Pediatric cardiac surgery is highly technical and risky. This newspaper article reports on a poorly performing pediatric cardiac surgery program, concerns raised by staff, and insufficient response from organizational leadership. Lack of data transparency, insufficient resources, and limited program capabilities to support a complex program contributed to poor outcomes for pediatric patients.
Hilton K, Anderson A. Harv Bus Rev. May 20, 2019.
This commentary describes how one health system worked to combat resistance to change associated with implementation of a checklist initiative. The success of the program was built on empowering team members to drive the process, clinician motivation to provide safe care, and engaging leadership. A PSNet interview with Lucian Leape discussed surgical safety checklists.
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.
CDC Vital Signs. May 7, 2019.
Maternal morbidity and mortality is a worldwide patient safety problem. This analysis describes the prevalence of pregnancy-related death and areas of concern during pregnancy, at delivery, and up to a year postpartum. It reports that 60% of these deaths are preventable and provides suggestions for families, clinicians, and systems to reduce risks.
Palmer J. Patient Saf Qual Healthc. May/June 2019.
Organizations must learn from adverse events to prevent similar incidents. Reporting on lessons to be learned from the cascade of failures connected with the preventable death of a patient during an acute asthma attack at the door of a hospital emergency department, this magazine article outlines the importance of effective signage, appropriate security staff placement, and acceptance of the responsibility for failure.
Jewett C. Kaiser Health News. May 3, 2019.
Transparency has been heralded as a cornerstone to improvement in health care. This news article reports on a government alternative summary reporting program that allowed medical device makers to conceal safety events and malfunction reports associated with medical devices. A new program that expands access to information about device-related failures will be put in place.
Frakt A. New York Times. April 29, 2019.
Health care providers are a known source of potentially harmful bacteria due to their perpetual interaction with germs during practice. This newspaper article reports on how clinician attire, stethoscopes, and technology can be contaminated with bacteria. Hand sanitizer placement, sleeve length, and laundering behaviors can reduce transmission of pathogens.
ISMP Medication Safety Alert! Acute Care Edition. April 25, 2019.
Newborns assigned temporary names are at increased risk for patient misidentification and wrong-patient errors. This newsletter article reports on the role of electronic health records in newborn misidentification and the unintended consequences associated with a Joint Commission set of recommendations to reduce risk.
Cheney C. HealthLeaders Media. April 17, 2019.
This news article describes how a 19-hospital health system successfully applied high reliability principles to emphasize a zero-tolerance focus on patient harm. The coordinated effort across the system achieved a drop in readmissions and physician burnout. Tactics used to improve reliability include huddles, purposeful redundancy, and leadership engagement.
Quick Safety. April 15, 2019;(48):1-3.
Fatigue, emotional stress, and illness can affect decision-making and lead to misuse of medications. This newsletter article describes the patient safety impacts of drug diversion among health care workers and notes the importance of a culture of constructive reporting to uncover and address this unsafe behavior.
Gordon M. Health Shots. National Public Radio. April 10, 2019.
Punitive responses to medical errors persist despite continued efforts to reduce them. This news article reports on an incident involving the mistaken use of a neuromuscular blocking agent that resulted in the death of a patient, the prosecution of the nurse who made the error, and systemic and human factors that contribute to similar events.
Erich J. EMS World. April 2019;48:26-31.
Air transport service combines risks associated with both aviation and prehospital trauma care. This article discusses the role of human factors in this fast-paced care environment. The author encourages efforts to reduce risks through policy change, purchasing the latest safety equipment, and empowering staff to decline calls when conditions are unsafe.
Field C, Finley E, Deutsch ES. PA-PSRS Pa Patient Saf Advis. 2019;16(1).
Schulte F, Fry E. Kaiser Health News, Fortune Magazine. March 18, 2019.
Despite years of investment and government support, electronic health records (EHR) continue to face challenges as a patient safety strategy. This news article outlines the unintended consequences of EHR implementation, including patient harm linked to software glitches and user errors, fraudulent behavior (upcoding), interoperability problems, clinician burnout due to poorly designed digital health records, and lack of industry transparency.
Dickson EJ. Rolling Stone. March 9, 2019.
Unintended consequences of restrictions enacted to combat the opioid crisis are a concern for patients and prescribers. This magazine article reports on an effort to raise awareness of the potential for patient harm due to lack of legitimate access to opioids for chronic pain as a result of the 2016 CDC opioid prescribing guidelines.
Rau J. Kaiser Health News. March 1, 2019.
Financial incentives may encourage adoption of practice improvements that enhance safety. This news article reports on the increase in United States hospitals that have had Medicare payments withheld due to high rates of hospital-acquired conditions. The article is accompanied by a state-level tally of individual hospitals penalized.
ISMP Medication Safety Alert! Acute Care Edition. February 28, 2019;24.
Medication warnings inform providers and patients about risks associated with medication use. As with other safety strategies, applying a systems approach to medication warnings can help redirect actions and prevent patient harm. This article describes design, content, and language characteristics of successful medication safety warnings. In addition, specific design and user-centered considerations are included to improve the effectiveness of electronic alerting.
Chisholm P. Health Shots. National Public Radio. February 27, 2019.
Another round of the blame game: a paralyzing criminal indictment that recklessly "overrides" just culture.
ISMP Medication Safety Alert! Acute Care Edition. February 14, 2019;24.
Span P. New York Times. February 1, 2019.
Cognitive and functional decline can occur as individuals age. Concerns have been raised regarding the need to assess skills of aging physicians. This newspaper article reports on the implementation of mandatory evaluation programs to assess competencies of older surgeons and the profession's response to them.
Janik LS, Vender JS Grissinger M, Litman RS. APSF Newsletter. February 2019;33:72-75.
This pair of commentaries reviews the use of color-coded medications as an anesthesia safety strategy. The first article argues for implementing standard color sets to delineate drug class and use to improve medication safety. The dissenting article suggests that color-coded medications may decrease the chance of clinicians reading syringe labels carefully due to overreliance on color representation as a shortcut for reading the label.
Hixenbaugh M, Ornstein C. Houston Chronicle and Propublica.
This news investigation chronicles a series of incidents in a transplant program that resulted in patient harm. The systemic nature of the problems such as insufficient whistleblower protection, accountability, and follow-up on patient concerns culminated in a change of hospital leadership. A previous PSNet interview with Charles Ornstein discussed the role of media in raising awareness of patient safety issues.
Park A. Time Magazine. January 24, 2019.
This news article reports on the documentary To Err Is Human, which was produced and directed by the son of patient safety leader Dr. John M. Eisenberg. The film is structured around patient safety advocate Sue Sheridan's experience with diagnostic errors that resulted in harm for both her son and husband. It features a wide range of experts who discuss the impact of error on all involved, the role of culture in facilitating both mistakes and progress, and why continued work in health care safety is needed.
Dembosky A. All Things Considered and KQED. January 23, 2019.
Policy, practice, and communication strategies have been implemented in an effort to stem the opioid crisis and prescribing activities that contribute to misuse. This news article and accompanying webcast discuss an initiative in California that sends letters to prescribers whose patients have died due to opioid overdose. The piece outlines unintended consequences associated with the practice, including clinician reluctance to prescribe opioids for pain. An Annual Perspective discussed the patient safety aspects of the opioid epidemic.
Safety enhancements every hospital must consider in wake of another tragic neuromuscular blocker event.
ISMP Medication Safety Alert! Acute Care Edition. January 17, 2019;24.
This newsletter article reports on the findings of a government investigation into the death of a patient during a positron emission tomography scan. A neuromuscular blocking agent was mistakenly administered instead of an anti-anxiety medication with a similar name. The investigation determined various individual and system failures that contributed to the incident, such as misuse of automated dispensing cabinets, wrong picklist medication selection, workarounds of override protections, and lack of patient monitoring. Recommendations for preventing similar incidents include use of barcoding verification, automated dispensing cabinet stocking changes, and labeling improvements.
Cierniak KH, Gaunt MJ, Grissinger M. PA-PSRS. Patient Saf Advis. 2018;15(4).
The operating room environment harbors particular patient safety hazards. Drawing from 1137 perioperative medication error reports submitted over a 1-year period, this analysis found that more than half of the recorded incidents reached the patient and the majority of those stemmed from communication breakdowns during transitions or handoffs. The authors provide recommendations to reduce risks of error, including using barcode medication administration, standardizing handoff procedures, and stocking prefilled syringes.
Rau J. Kaiser Health News. December 3, 2018.
Beck DL. ASH Clinical News. December 1, 2018.
ISMP Medication Safety Alert! Acute Care Edition. November 29, 2018;23:1-6.
Look-alike and sound-alike medications present a recurring threat to patient safety. This newsletter article summarizes an analysis of reported drug name confusion errors. Although incidents seem to have decreased over time, the influx of generic drug names is contributing to the persistence of the problem. Increased federal attention to the issue, provider use of known strategies to improve practice, and pharmaceutical company testing of names to avoid similarities can help reduce drug name confusion.
McGrory K, Bedi N. Tampa Bay Times. November 28, 2018.
Mohr H, Weiss M. Associated Press. November 27, 2018.
Graham J. Kaiser Health News. November 21, 2018.
Patients can identify errors in their medical records that health care providers may not recognize. This news article highlights the importance of patients correcting seemingly simple mistakes such as name misspellings and phone numbers as these errors can contribute to situations that result in patient harm.
Simmons-Ritchie D. Penn Live. November 15, 2018.
Nursing home patients are vulnerable to preventable harm due to poor safety culture, insufficient staffing levels, lack of regulation enforcement, and misaligned financial incentives. This news investigation reports on how poor practices resulted in resident harm in Pennsylvania nursing homes and discusses strategies for improvement, such as enhancing investigation processes.
Wild D. Pharmacy Practice News. November 8, 2018.
Medication safety officers serve as organizational champions of medication management process improvement. This news article offers two examples of health care organizations that positioned medication safety officers as leaders in their systems. The piece describes improvements stemming from employment of medication safety officers at these organizations.
DeMarco P. Globe Magazine. November 3, 2018.
This magazine article reports on the preventable death of a patient during an acute asthma attack. Written by the patient's husband, the article outlines the failures that led to her death despite the fact that she was at the door of a hospital emergency department and on the phone with an emergency dispatcher. Factors discussed include overreliance on poorly functioning technology, communication failures, and lack of fail-safes.
Gawande A. New Yorker. November 12, 2018.
In this magazine article, Atul Gawande describes a range of frustrations physicians experience as digitization becomes more widespread in health care. He elaborates upon several elements of electronic health record use that can degrade care processes and create conditions for errors, such as burnout, lack of patient-centeredness, and alert fatigue.
ISMP Medication Safety Alert! Acute Care Edition. November 1, 2018;23:1-5. November 15, 2018;23:1-5.
Errors in the administration of intravenous medications can result in patient harm. This set of articles discusses the results of a nationwide IV push medication survey. The first article reviews unsafe practices in care delivery as defined by inpatient clinicians. The second article recommends ways to improve practice such as assessment of current practices, use of prefilled syringes, and heightened attention to effective labeling.
Gipson K. PA-PSRS Pa Patient Saf Advis. 2018 Oct 31;15(suppl 1):39-45.
van der Heijde R, Deichmann D. Harv Bus Rev. October 30, 2018.
Aviation continues to provide inspiration for patient safety innovation. This commentary describes a 10-minute team huddle exercise which involves team members rating their own mood status and the leader asking if there are any contextual concerns. In addition, two team members select "knowledge cards" that either test the person's knowledge or assign the person to proactively watch for improvement opportunities during the shift. The results encouraged sharing, situational awareness, and team building.
Parikh R. MIT Technol Rev. October 23, 2018.
Computerized decision support and artificial intelligence (AI) are being utilized to enhance decision-making in health care. This magazine article explains how artificial intelligence presents clinicians with an opportunity to improve practice by reducing cognitive load when determining appropriate diagnoses and treatment decisions.
Kaiser Health News.
Peeples L. Pharmacy Practice News. October 10, 2018.
Structured handoffs can reduce communication problems that contribute to medical error. This magazine article reports on how I-PASS implementation can help enhance the quality and completeness of handoffs, highlights the need for pharmacists to be more engaged in handoff improvement, and offers insights for enhancing their role in the process. In a past PSNet interview, Dr. Amy Starmer discussed the implementation and findings of the landmark I-PASS study.
Mix-ups between epidural analgesia and IV antibiotics in labor and delivery units continue to cause harm.
ISMP Medication Safety Alert! Acute Care Edition. October 4, 2018;23:1-4.
Increased urgency to prevent maternal mortality has uncovered various factors that diminish safety. This newsletter article reports on incidents involving the accidental misuse of epidural analgesia and intravenous antibiotics in labor and delivery care, describes contributing factors (e.g., health technology missteps, barcoding mistakes, and look-alike medications), and offers improvement strategies to mitigate harm.
Peskin SM. New York Times. October 4, 2018.
Error disclosures are difficult but important conversations that can have negative consequences for patients, clinicians, and organizations, even when they are done appropriately. This newspaper article offers insights from a doctor who experienced both sides of disclosure, as a physician disclosing an error and as a patient whose physician missed a complication, and discusses how to manage relationships once clinical mistakes are recognized.
Biel L. ProPublica. October 2, 2018.
This news article reports on systemic weaknesses that enabled a surgeon with poor skills to continue to perform procedures after numerous surgical errors that resulted in patient harm. A past PSNet perspective explored the risk of recurring medicolegal events among providers who have received unsolicited patient complaints, faced disciplinary actions by medical boards, or accumulated malpractice claims.
Quick Safety. October 1, 2018;(45):1-2.
This newsletter article reviews common problems related to patient identification and recommends strategies to ensure verification actions are a part of daily practice. Highlighted suggestions focus on system-level approaches that reduce the potential for incorrect patient data to be entered and proliferate, such as use of frontline confirmation processes and duplicate record monitoring. A WebM&M commentary discussed an incident involving a wrong-patient order in an electronic record system.
Liberatore K. PA-PSRS Patient Saf Advis. 2018;15(3).
Engaging patients and families in patient safety efforts is a key priority in health care. This poll of patients from Pennsylvania explores actions patients are likely to take to ensure their safe care. The results indicate a strong willingness to ask questions to help patients better understand their care, but patients were uncomfortable with raising concerns if they saw clinician behaviors that diminish safety, such as lack of hand hygiene compliance.
Sederstrom J. Drug Topics. September 17, 2018.
Medication errors continue to be a worldwide patient safety challenge that requires both systems and individual practice strategies for improvement. This magazine article describes how pharmacists can address failures associated with processing, dosing, care transitions, and information sharing to prevent medication errors.
Decerbo M. Pharmacy Practice News. September 13, 2018.
Parenteral nutrition errors can result in patient malnutrition and harm. Reporting on how insufficient understanding of malnutrition contributes to its presence in health care, this news article suggests that both general guidelines and tailored approaches to nutrition are necessary to keep hospitalized patients safe. Improvements in addressing the complicated needs of patients who are older or have cancer illustrate progress made toward the effective delivery of nutrition.
Canadian Medical Protective Association. CMPA Perspective. September 2018;10:8-11.
Frontline leadership should model just culture behaviors to encourage reporting and discussion of error to facilitate improvement. This news article uses a medical administration error to examine whether human error, at-risk behavior, or reckless action on the part of a clinician led to the mistake and explores leadership response to the incident to determine accountability in each type of situation.
Schulte F, Lucas E, Mahr J. Kaiser Health News and Chicago Tribune. September 5, 2018.
Sepsis is a serious condition that can be fatal if it is not promptly diagnosed and treated. This news article reports on systemic factors in nursing homes such as poor staffing and communication with families that contribute to unmanaged pressure ulcers and sepsis that result in hospital admissions and death. A WebM&M commentary discussed a case involving a patient who had a pressure ulcer and sepsis in long-term care.
Howley EK. US News & World Report. September 5, 2018.
Communication failures in health care routinely challenge patient safety. This news article describes characteristics of the hospital environment that affect nurse–physician relationships such as bullying, production pressure, and care complexity. Clarifying team roles and interdisciplinary activities can improve communication in the care environment. Patients are encouraged to have advocates with them to help prevent and address misunderstandings.
Eldred SM. Health Shots. National Public Radio. August 15, 2018.
Using professional interpreters can avert risks of miscommunication due to language barriers between patients and clinicians. This news article discusses how lack of qualified medical interpreters, use of ad hoc interpreters, and poor patient understanding of instructions can contribute to adverse events. A WebM&M commentary explored patient safety issues associated with patient–clinician language differences.
Fetters A. The Atlantic. August 10, 2018.
Women face implicit bias that can affect the safety and effectiveness of their care. Reviewing several high-profile accounts that raised awareness of challenges women experience in health care, this magazine article describes challenges to safe care such as lack of physician attention to patient concerns, misdiagnosis, and preconceptions regarding pain intensity.
Jewett C, Alesia M. Kaiser Health News. August 9, 2018.
High-profile failures during office-based procedures have raised awareness of the potential safety hazards of surgery centers and the need for improved oversight. This news article reports on safety events in ambulatory surgical centers and insufficiencies in incident reporting and analysis. Enhanced transparency regarding those failures can enable informed patient decision-making when choosing care providers.
Young A, Kelly J, Schnaars C, Ungar L. USA Today.
Students have a key role in a culture of safety: analysis of student-associated medication incidents.
ISMP Medication Safety Alert! Acute Care Edition. July 26, 2018;23:1-4.
Previous studies have discussed concerns associated with new clinician involvement in care delivery. This data analysis highlights how organizational culture affects student-related errors and summarizes the positive contribution students bring to medication safety, including new perspectives, recently acquired evidence, and a willingness to ask questions.
Arndt RZ. Mod Healthc. July 14, 2018.
Similarities in patient names and clinical situations can result in medical errors. Discussing how digital technologies can exacerbate patient identification problems, this magazine article describes unique elements of information systems that enable mistakes to spread quickly, outlines costs associated with patient mismatches, and recommends improvement strategies such as use of unique patient identifiers. A past WebM&M commentary reviewed an incident involving a patient mix-up.
ISMP Medication Safety Alert! Acute Care. July 12, 2018;23:1-4.
Smart pumps are employed throughout health care, but their design can challenge safety. Reporting results of a national survey, this newsletter article outlines how smart pump data is being used to improve compliance and suggests ways organizations can enhance the value of analytics to inform frontline practice improvement. A previous WebM&M commentary discussed a smart infusion pump error that resulted in patient harm.
Bruley ME, Arnold TV, Finley E, Deutsch ES, Treadwell JR. PA-PSRS Pa Patient Saf Advis. June 2018;15.
Although surgical fires are considered never events, they continue to occur. This article reports findings from an analysis of 28 operating room fire incidents submitted over a 5-year period to the Pennsylvania Patient Safety Reporting System. Although incidence of surgical fires has significantly decreased since earlier reporting periods, half of the reported events resulted in patient harm. A past WebM&M commentary discussed surgical fires and how to prevent them.
R3 Report. June 25, 2018;7:1-2.
Gale SF. Chief Learning Officer. July/August 2018;17:22-25.
Hoffman RM, Mirarchi FL. PA-PSRS Patient Saf Advis. June 2018;15.
Patient harm associated with advance directive interpretation errors is rare, but these mistakes can have negative psychological consequences for care teams, patients, and families. Discussing research exploring factors that contribute to these misunderstandings, this article recommends actions to help patients articulate end-of-life care preferences and ensure those instructions are accurately shared with their families and the clinical teams acting on their behalf.
ISMP Medication Safety Alert! Acute Care Edition. June 14, 2018,23:1-5. June 28, 2018;23:1-4,6,7.
Mistakes in the use of vaccines can have both individual and public health implications. The first article of this series reviews the results from an analysis of reports submitted to a national error reporting system to track vaccine-related errors. The second article offers recommendations to help immunization and vaccination programs address product-, knowledge-, and practice-related factors that contribute to process weaknesses, including training, storage, and labeling strategies.
Rau J. Kaiser Health News. June 13, 2018.
Safety problems are common in nursing homes due to challenges such as poor safety culture, staff burnout, and inappropriate polypharmacy. Describing how medication missteps and communication errors can diminish safety of residential care, this news article discusses system-level incentives that can either contribute to avoidable hospital readmissions of long-term care patients or be employed to improve practice.
The Economist. June 7, 2018.
Artificial intelligence (AI) can improve the timeliness and accuracy of decision making in health care. This magazine article reports on how AI use in medicine can affect diagnosis of cancers, stroke, and cardiac arrhythmia. The piece underscores that though these improvements may look impressive, human knowledge will still be necessary to achieve the full benefit of AI applications for health care improvement.
ISMP Medication Safety Alert! Acute Care Edition. May 31, 2018;23:1-4.
Smart pumps offer both benefits and drawbacks that can affect medication safety. This newsletter article explores missteps related to lack of compliance with setting hard stops to protect patients when using unique intravenous medication concentrations. Recommendations to prevent errors include using standardized dosing concentrations as often as possible, adhering to metric unit dosing requirements, and verifying pump programming settings.
Kowalczyk L. Boston Globe. May 27, 2018.
Pediatric patients are particularly vulnerable to medication errors. This news article reports on serious medication errors that occurred at Children's Hospital in 2017, the underlying system failures that contributed to the incidents, and challenges to implementing new policies meant to prevent similar errors.
Headley M. Patient Saf Qual Healthc. May/June 2018.
Clinicians can experience emotional stress, guilt, and insecurity after making a mistake. Organizations are increasingly building programs to enable second victims to return to safe and confident practice. This magazine article highlights factors that contribute to success of second victim support programs, such as an established culture of safety, focus on emotional needs rather than skill assessment, and sustained leadership engagement in the program.
Mukherjee S. New York Times Magazine. May 9, 2018.
Checklists can coordinate action and communication to augment safety, but human and system factors may hinder their effectiveness. This magazine article reports on how the checklist phenomenon evolved into a global patient safety effort and spotlights the impact of human behavior on reliable implementation of checklist programs in different care environments.
Burt A, Volchenboum S. Harv Bus Rev. May 8, 2018.
O'Loughlin E. New York Times. April 30, 2018.
Large-scale adverse events should lead to system examination and improvement. This newspaper article reports on misread cervical cancer tests that resulted in 208 women receiving false negative results over a 4-year period from a publicly funded smear test program in Ireland and the government inquiry launched in response to this large-scale failure.
Porter S. HealthLeaders Media. April 26, 2018.
Overreliance on technology can result in harmful medication mistakes. Reporting on a 10-fold medication overdose that led to the death of a patient with dementia, this news article describes how the hospital changed their processes to improve medication safety, which included restructuring medication safety leadership, modifying the electronic health record to address alert overrides, and enhancing information sharing to support learning and transparency.
Crouch M. Reader's Digest. April 2018.
Involving patients in their care can help improve safety. This magazine article provides 34 tips from leading patient safety experts to assist patients in this role. Tactics include considering a second opinion, bringing an up-to-date medication list, and repeating information back to providers to reduce misunderstandings.
The next generation of doctors may be learning bad habits at teaching hospitals with many safety violations.
Blau M. STAT. April 20, 2018.
The hidden curriculum, staff burnout, and other organizational norms contribute to behaviors that put both care teams and patients at risk. Reporting on clusters of safety violations the Centers for Medicare and Medicaid Services found at teaching hospitals, this news article suggests that trainees who learn in environments where patients receive unsafe care may perpetuate poor practices and reviews how teaching hospitals are working to change behavior and educate trainees about patient safety.
ISMP Medication Safety Alert! Acute Care Edition. April 5, 2018;23:1-5.
Smart pumps are considered an important tool to improve medication safety in the hospital environment. This newsletter article summarizes the results of two national surveys on smart infusion pump use to highlight current concerns and challenges to generating improvements. Irrelevant alarms and out-of-date drug libraries were among the problems identified by survey participants.
Pharmacy Practice News. April 4, 2018.
Despite considerable effort, medication errors continue to occur and result in patient harm. Summarizing reports of medication mistakes submitted to the Institute for Safe Medication Practices for analysis, this news article describes types of problems, prevention strategies, and technologies that can reduce risks.
Wachter R, Goldsmith J. Harv Bus Rev. March 30, 2018.
Increased workload associated with electronic health record (EHR) documentation contributes to physician burnout. Describing challenges associated with poor user interface of EHRs, this magazine article recommends use of artificial intelligence, redesigning workflow, and enhancing alert systems to improve the usefulness of EHRs.
Quick Safety. March 27, 2018;(40):1-2.
Falls are a common patient safety concern for adults but are rarely discussed as a threat to newborn safety. This newsletter article provides a definition for a newborn fall or drop, highlights factors that increase risks of such incidents, and offers recommendations to augment safety such as rounding to monitor parent fatigue and reporting of events to inform improvements.
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.
Liberatore K. PA-PSRS Patient Saf Advis. 2018 March;15.
Latex products are widely available in hospitals and represent a persistent threat to patients with latex allergies. Drawing from 616 reported latex-related events, this investigation found that more than half of the incidents were associated with indwelling urinary catheter use. Tracking staff awareness of latex allergies, purchasing latex-safe alternatives, and improving handoff documentation of patient allergies are possible risk reduction strategies. A WebM&M commentary discussed allergy documentation in patient health records.
Meyer TA, McAllister RK. Pharmacy Practice News. March 19, 2018.
Perioperative adverse drug events are common and understudied. Reporting on the complexity of medication administration during surgery, this news article reviews strategies to reduce risks of surgical adverse drug events. Specific tactics discussed include proactive problem identification, medication reconciliation, high-alert medication process vigilance, verbal order reduction, and information technology optimization.
Bartolone P. Kaiser Health News. March 16, 2018.
Drug shortages may require clinicians, pharmacists, and hospitals to divert from standard processes to address gaps. This news article reports how reduced opioid production as an approach to address the opioid crisis has led to shortages and subsequent patient harm, such as insufficient pain management for surgical, cancer, and trauma patients.
Montagne R. Weekend Edition Sunday. National Public Radio. March 11, 2018.
Maternal death is a sentinel event. This news audio segment reports on childbirth-related death in the United States and firsthand accounts of complications associated with childbirth, such as infection. The interview also discusses how misdiagnosis contributes to the severity of problems. This piece is part of an ongoing series on the safety of maternal care.
Daley J. Colorado Public Radio. February 23, 2018.
Innovations in the prescribing of opioids in the emergency department are needed to change practice and help address the opioid crisis. This news article reports the results of a 10-hospital pilot program, the Colorado Opioid Safety Collaborative, which used alternative pain control approaches to reduce opioid prescriptions by an average of 36%. The program builds on multidisciplinary teamwork to modify pain management in the emergency department. An Annual Perspective highlighted opioid misuse as a patient safety challenge.
ISMP Medication Safety Alert! Acute Care Edition. February 22, 2018;23:1-5.
Myriad system and clinician failures can contribute to medication errors. This newsletter article reviews factors that contribute to nebulized medication administration problems, such as unlabeled solutions, look-alike packaging, equipment misuse, and storage issues. Recommendations to reduce risks include team assessment of barcode scanning processes, communicating orders, and storing vials separately.
Crane M. Medscape Business of Medicine. February 20, 2018.
Carr S. ImproveDx. February 2018;5:1-4.
Lack of attention to patient context can affect care safety. This newsletter article reports concerns associated with accurate diagnosis that transgender patients may encounter. The author discusses how bias, poor communication, and uncertainty contribute to potential problems and suggests that patient-centered respectful care is key to improving diagnosis.
Vosper H, Lim R, Knight C, Bowie P, Edwards B, Hignett S; CIEHF Pharmaceutical Human Factors Special Interest Group. Clinical Pharmacist. 2018;10(2).
Traditionally, efforts to reduce medical errors have focused on modifying individual behavior rather than systems. This article reviews the use of systems thinking models to address failure and discusses how small problems can combine into organizational failure. The authors suggest that the health care workforce develop human factors engineering competencies to achieve improvements.
Quick Safety. January 22, 2018;(39):1-3.
ISMP Medication Safety Alert! Acute Care Edition. January 11, 2018;23:1-4.
Drug shortages are known to disrupt the safety of care. This newsletter article reports the results of a survey exploring the impact of drug shortages on practice and recommends strategies to help organizations safely manage drug shortages, including standardizing processes and raising awareness among clinicians regarding shortages.
The science of safety: trustees can play a crucial role in fostering a safety culture at their hospitals.
Fairbanks RJ, Krevat SA. Trustee Magazine. January 8, 2018.
Safety sciences offer methods to enhance processes and develop organizational culture. This magazine article reports on safety science approaches that have improved safety in high-risk industries and concepts such as learning from failure and transparency that should be encouraged by leadership in health care.
Rau J. Kaiser Health News. January 5, 2018.
Magee MC, Miller K, Patzek D, Madera C, Michalek C, Shetterly M. PA-PSRS Patient Saf Advis. December 2017;14.
Near misses provide unique opportunities to identify and learn from safety hazards. Describing how one organization utilized data on near misses involving barcode medication administration over a 12-year period to reduce barcode-workflow events, this report outlines practices and strategies that contributed to success such as promoting event reporting and applying root cause analysis.
Burger C, Eaton P, Hess K, et al. Patient Saf Qual Healthc. December 12, 2017.