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- WebM&M Cases 2
- Study 7
- Audiovisual 5
- Book/Report 5
- Newspaper/Magazine Article 48
- Special or Theme Issue 1
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- Web Resource 9
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Communication between Providers
- Sbar 1
- Communication between Providers 22
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- Students 1
- Error Reporting and Analysis 15
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- Device-related Complications 4
- Diagnostic Errors 11
- Discontinuities, Gaps, and Hand-Off Problems
- Fatigue and Sleep Deprivation 4
- Identification Errors 5
- Medical Complications 6
- Medication Safety 19
- Nonsurgical Procedural Complications 1
- Psychological and Social Complications 3
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- Ambulatory Care 11
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Health Care Providers
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Non-Health Care Professionals
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Search results for "Patients"
Hartocollis A. New York Times. September 25, 2008; Metropolitan Desk section: A1.
This news article reports on the dynamic between patient safety and privacy in the use of color-coded bracelets that indicate patient preferences related to end-of-life care.
Landro L. Wall Street Journal. May 28, 2008:D1.
This article reports how hospitals are aiming to boost the safety of care delivered on nights and weekends by employing "nocturnists" (a hospitalist subspecialty)—physicians who work only the night shift.
Cooney E. Worcester Telegram & Gazette. January 28, 2008;Living section:E1.
This article discusses an AHRQ-funded program to study information technology tools and their ability to minimize medication errors in a geriatric patient population.
Alexander M. Reader's Digest. June 2007.
This article reports on the potential for medical errors to occur during the night shift and the factors that contribute to these mistakes.
Rockville, MD: Agency for Healthcare Research and Quality. April 25, 2007.
This podcast features an interview with Agency for Healthcare Research and Quality (AHRQ) Director Carolyn Clancy discussing handoffs in health care and how a patient can help in making handoffs more reliable. A companion piece for the clinician is also available.
Paterson R. Auckland, New Zealand: Office of the Health and Disability Commissioner; April 24, 2007.
This report analyzes an incident of medication error that led to a patient's death, discusses the subsequent actions taken by the health board, and calls for a coordinated approach to medication reconciliation in New Zealand.
Kowalczyk L. Boston Globe. April 21, 2007:B1.
This article reports on the results from Joint Commission site inspections of five Boston-area hospitals.
Brown D. Washington Post. April 10, 2007:HE01.
This article describes the Veterans Affairs' universal medical records network and illustrates how use of electronic medical records at VA medical centers supports safe care.
Landro L. Wall Street Journal. April 4, 2007:D5.
This article reports on initiatives to standardize the color designations of color-coded wristbands to avoid confusion and reduce the risk of error.
Urbina I, Nixon R. New York Times. March 30, 2007;National Desk section:1.
This article reports on the inconsistent use of the Department of Defense electronic medical records system and how this has led to medical errors and delays in care for US veterans.
Blaney B. Associated Press [USA Today]. March 12, 2007.
This article reports on the abduction of a newborn by an individual masquerading as a hospital employee. Infant abduction is one of the patient safety "never events" defined by the National Quality Forum.
Wolfe W. Minneapolis Star Tribune. February 28, 2007.
This article reports on three patient deaths due to errors at a state-owned nursing home for veterans.
Breast Cancer Services in Trafford and North Manchester. An Investigation Into The Circumstances Surrounding A Serious Clinical Incident In Symptomatic Breast Services – The Baker Report.
Baker M. Manchester, England: NHS North West; February 2007.
This report shares findings from an investigation into individual and system failures that contributed to a radiologist misreading mammograms for a 2-year period.
Groopman J. The New Yorker. January 29, 2007;47:36-41.
The author discusses how heuristics can lead to errors in physician judgement and decision making.
Vesely R. Inside Bay Area. December 28, 2006.
This article describes a variety of quality and safety problems in the labor and delivery ward at a large public hospital.
Landro L. Wall Street Journal (Eastern edition). November 29, 2006: D1-D5. [Reprinted on Post-gazette.com].
This article describes a decision support program used by Kaiser Permanente and U.S. Veterans Administration to help minimize misdiagnosis.
Lerner BH. The Washington Post. November 28, 2006:HE01.
The author reviews the legacy of Libby Zion and how her untimely death raised awareness of the impact that resident duty hours and fatigue could have on patient care and quality.
Grant > Government Resource
Rockville, MD: Agency for Healthcare Research and Quality; June 2008.
This announcement describes the 19 projects funded by the Agency for Healthcare Research and Quality in 2006 that studies the potential of simulation to improve patient safety.
Gulliver D. Sarasota Herald Tribune. November 7, 2006:BS1.
This article reports on the death of a restrained patient and outlines the factors affecting the subsequent reporting of the event.
Journal Article > Study
Coleman EA, Parry C, Chalmers S, Min SJ. Arch Intern Med. 2006;166:1822-1828.
Prior studies have documented the safety problems that befall patients with complex illnesses at the time of transition from one setting of care to another. In this trial conducted in an integrated delivery system, patients were randomized to receive usual care or the care transitions intervention at the time of hospital discharge. Intervention patients received a personal health record and a "transition coach," who assisted with continuity of care across settings, arranged home visits after discharge, and helped train patients and caregivers in self-care methods. The foci of the intervention were on ensuring accurate medication usage and appropriate follow-up care. The intervention successfully reduced the likelihood of hospital readmission for 3 months after discharge and appeared to be cost effective.