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- Communication Improvement 13
- Culture of Safety 10
- Education and Training 6
Error Reporting and Analysis
- Error Reporting 30
- Human Factors Engineering 10
Legal and Policy Approaches
- Regulation 30
- Logistical Approaches 4
- Policies and Operations 1
- Quality Improvement Strategies 18
- Specialization of Care 1
- Teamwork 1
- Technologic Approaches 7
- Transparency and Accountability 1
- Device-related Complications 3
- Diagnostic Errors 3
- Discontinuities, Gaps, and Hand-Off Problems 5
- Drug shortages 2
- Fatigue and Sleep Deprivation 2
- Identification Errors 1
- Medical Complications 11
- Medication Errors/Preventable Adverse Drug Events 10
- Overtreatment 1
- Psychological and Social Complications 1
- Second victims 1
- Surgical Complications 13
- Internal Medicine 23
- Nursing 6
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- Family Members and Caregivers 5
- Health Care Executives and Administrators 70
Health Care Providers
- Nurses 4
- Physicians 15
Non-Health Care Professionals
- Media 3
- Policy Makers
- Patients 45
Search results for "Policy Makers"
- Newspaper/Magazine Article
- Policy Makers
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.
Mello MM, Kachalia A, Studdert DM. Issue Brief (Commonw Fund). 2011;14:1-18.
This piece discusses the no-fault medical injury compensation programs of Denmark, Sweden, and New Zealand and explores how elements of these programs can be applied to compensation efforts in the United States.
Ivill DS, Kearbey AH. New York Law J. November 2, 2009.
This news feature discusses legal aspects of Patient Safety Organizations' (PSO) role in data collection and evaluation, work product designation, confidentiality protection, and organizational structure. In addition, the authors suggest key considerations to guide effective PSO implementation.
Weise E. USA Today. May 18, 2005.
Hospital-error oversight called lax: state takes too long to investigate mistakes, patient advocates say.
Galloway A. Seattle Post-Intelligencer. May 5, 2005.
This article explores inefficiencies in the process for reporting and investigating adverse events in Washington and indicates that inconsistent error review is a problem across the nation.
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.
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.
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.
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.
Rau J. Kaiser Health News. December 3, 2018.
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.
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.
Abbasi J. JAMA. 2016;316:698-700.
The presence of medical errors in health care is universally recognized, but the estimated number of preventable adverse events remains controversial. Discussing a controversial study that reported more than 250,000 deaths attributable to medical error occur each year in the United States, this news article offers insights from patient safety leaders regarding the various challenges to identifying and measuring medical error.
Ghaferi AA, Myers C, Sutcliffe KM, Pronovost PJ. Harv Bus Rev. July/August 2016;94.
Achieving high reliability is a recognized goal for health care organizations. Reviewing current technical and standardization enhancements to augment quality and safety in surgery, this article explores how implementing high reliability concepts could further improve safety in surgical care over time.
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.
Landro L. Wall Street Journal. May 9, 2016.
Closed claims have been considered a source for adverse event data for years, and recently such data has been utilized to inform safety improvement work. This newspaper article reviews several organizational efforts that use claims data to determine factors that contribute to failure and strategies to address them, including process redesign and enhanced patient education.