Narrow Results Clear All
- Communication Improvement 10
- Culture of Safety 2
Education and Training
- Students 5
- Error Reporting and Analysis 4
- Human Factors Engineering 1
- Legal and Policy Approaches 3
- Logistical Approaches 3
- Quality Improvement Strategies 2
- Research Directions 1
- Teamwork 2
- Technologic Approaches 1
- Device-related Complications 1
- Diagnostic Errors 2
- Discontinuities, Gaps, and Hand-Off Problems 2
- Fatigue and Sleep Deprivation 3
- Medication Safety 5
- Nonsurgical Procedural Complications 1
- Psychological and Social Complications 4
- Surgical Complications 1
- Family Members and Caregivers 3
- Health Care Executives and Administrators 10
Health Care Providers
- Nurses 1
- Non-Health Care Professionals
Search results for "Patients"
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.
Journal Article > Study
Improving the patient, family, and clinician experience after harmful events: the "When Things Go Wrong" curriculum.
Bell SK, Moorman DW, Delbanco T. Acad Med. 2010;85:1010-1017.
Medical errors have a lasting effect on patients and their families but can also leave providers—the "second victim"—with a similar emotional toll. Error disclosure is increasingly viewed as an essential skill for physicians just as training curriculums and guidelines continue to emerge. This study describes an interactive educational curriculum for trainees and faculty physicians that teaches error disclosure, apology, and explores the human impact of error. Among the participants, 62% of trainees and 88% of faculty reported making a medical error, while 62% and 78% of them, respectively, did not apologize, citing the lack of training to do so. The authors share the development of their curriculum, its evaluation, and also provide a tool to address practical issues related to communication and professionalism following an adverse event. Past AHRQ WebM&M perspectives have discussed error disclosure and new developments in the field.
Tools/Toolkit > Multi-use Website
Johns Hopkins University, Department of Anesthesiology & Critical Care Medicine.
This Web site provides information on the multidisciplinary safety team at Johns Hopkins University, including research projects, presentations, and useful tools for patients, families, and practitioners.
Middleton, MA: HealthLeaders Media. ISSN: 1553-6637.
Beginning with its inaugural issue in August 2004, Patient Safety and Quality Healthcare (PSQH) is published bi-monthly. News from the field and articles by industry experts round out the content. PSQH seeks to inform patients, clinicians, patient safety officers, risk managers, business leaders, policy makers, educators, and commercial vendors working in all health care settings.
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.
Chisholm P. Health Shots. National Public Radio. February 27, 2019.
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.
Hurt J. Med Econ. April 26, 2017.
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.
Boodman SG, Kaiser Health News. Washington Post. May 19, 2014.
Khullar D. New York Times. May 15, 2014.
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.
Chen PW. New York Times. April 18, 2013.
Journal Article > Study
Wolf MS, King J, Jacobson K, et al. J Gen Intern Med. 2012;27:1587-1593.
Overdose of acetaminophen—a commonly used over-the-counter medication—is the leading cause of acute liver failure in the United States, with the majority of cases being unintentional. Prior studies have shown that patients with limited health literacy frequently misunderstand dosing instructions for prescription medications, and this study examined the frequency with which adult patients misunderstood dosing instructions for acetaminophen. Patients were provided with actual bottles of medications and asked to demonstrate how many pills they could take during a day, alone or in combination with other analgesics. Under these simulated conditions, nearly half the patients would have overdosed either by exceeding the recommended daily dose of acetaminophen or by combining two acetaminophen-containing products. An AHRQ WebM&M commentary discusses a case of liver injury caused by incorrect dosing of acetaminophen.
Journal Article > Study
Patients' attitudes towards patient involvement in safety interventions: results of two exploratory studies.
Davis RE, Sevdalis N, Pinto A, Darzi A, Vincent CA. Health Expect. 2013;16:e164-e176.
An educational intervention increased the likelihood that patients would participate in safety behaviors, such as asking providers about hand hygiene. Proposed roles for patients in patient safety are discussed in more detail in this Patient Safety Primer.
Dunklin R, Goetinck Ambrose S, Egerton B. Dallas Morning News. August 1, 2010:A01.
This newspaper article reveals how one teaching hospital facilitated error through ineffective resident training, weak oversight, and poor safety culture.
Chen PW. New York Times. October 1, 2009.
This column discusses how life stresses affect the reliability and safety of care provided by over-extended clinicians in light of a recent study on the topic.
Chen PW. New York Times. July 9, 2009.
This column shares one physician's experience with the deterioration of a colleague's practice after involvement in error. The piece highlights the need for effective support of physicians-in-training to manage and respond to mistakes.
Bohan S. Oakland Tribune. January 27, 2007.
This article describes how simulators are being used by hospitals to train medical teams on effective communication and teamwork.
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.