Narrow Results Clear All
- Communication Improvement 8
- Culture of Safety 4
- Education and Training 2
- Error Reporting and Analysis 8
- Human Factors Engineering 15
- Legal and Policy Approaches 7
- Logistical Approaches 3
- Quality Improvement Strategies 3
- Technologic Approaches 12
- Alert fatigue 1
- Device-related Complications 5
- Diagnostic Errors 1
- Discontinuities, Gaps, and Hand-Off Problems 3
- Drug shortages 1
- Fatigue and Sleep Deprivation 3
- Identification Errors 4
- Interruptions and distractions 1
- Medical Complications 2
- Medication Errors/Preventable Adverse Drug Events 5
- Nonsurgical Procedural Complications 1
- Psychological and Social Complications 6
- Second victims 1
- Allied Health Services 1
- Internal Medicine 17
- Nursing 4
- Pharmacy 4
- Family Members and Caregivers 3
- Health Care Executives and Administrators 36
Health Care Providers
- Nurses 4
Non-Health Care Professionals
- Engineers 11
- Media 2
- Patients 12
Search results for "Latent Errors"
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.
Weber T, Ornstein C. Los Angeles Times. April 12, 2005.
This article reports on a death that occurred at the Martin Luther King Jr./Drew Medical Center after a patient's deteriorating vitals signs went unnoticed.
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.
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.
Mohr H, Weiss M. Associated Press. November 27, 2018.
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.
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.
Landro L. Wall Street Journal. August. 8, 2016.
First-year residents may be reluctant to ask for assistance due to factors such as peer pressure to demonstrate competency. This newspaper article reports on one hospital's strategy to enhance communication among residents and attendings, which encourages residents to ask questions of senior clinicians who are coached to welcome learning conversations.
Rosen AK, Chen Q. National Quality Measures Clearinghouse: Expert Commentaries; June 13, 2016.
The current measures designed to enable transparency and accountability are falling short of helping to reach those goals. This article discusses weaknesses in the existing metrics used to track patient safety improvement. Factors contributing to the problem include the myriad of measure sets, reliance on retrospective data collection and analysis, and gaps due to inconsistent methods of engaging patients and families in reporting safety-related events.
Hunt JM, Sine DM. Patient Saf Qual Healthc. May/June 2016;13:20-28.
Design is emerging as an important tactic to augment safe care delivery. Hospitals that provide care for psychiatric patients must make unique considerations to protect this vulnerable population from harming themselves and other individuals that come into contact with them. This magazine article provides recommendations for hospitals to enhance room and fixture designs to reduce risks for mental health patients.
Eagle A. Hosp Health Netw. October 14, 2014.
Stempniak M. Hosp Health Netw. September 9, 2014.
Involving patients and their families in bedside rounds, advisory committees, and shift change has helped hospitals achieve improvements in patient safety. This news article spotlights several successful patient engagement programs and offers tips to help sustain the progress made by these new practices.
Addis LM, Cadet VN, Graham KC. Patient Saf Qual Healthc. May/June 2014.
Reese SM. Information Week. March 11, 2014.
This article describes how wearable technologies for clinicians can improve workload distribution, information gathering, and staffing decisions to address safety issues, particularly nurse fatigue.
Munn J. PA-PSRS Patient Saf Advis. March 2014;11:23-29.
Patients are increasingly being asked to assume a role in ensuring their own safety. This report explores patients' adoption of practices meant to help improve their safety and found that 8 of the 10 suggested tactics are actively used by health care consumers in Pennsylvania.
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.
MacLeod L. Physician Exec. Jan-Feb 2014;40:8-12.
Second victims are clinicians who experience considerable emotional distress, shame, and self-doubt after being involved in a medical error. This magazine article discusses the need for hospitals to provide care for these clinicians and spotlights the role of physician leaders in promoting and facilitating support programs.
Jaffe E. Fast Company. November 11, 2013.
This article reports on a British initiative that studied health care processes for the purpose of designing devices to prevent medical errors.