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Search results for "Patients"
- Error Analysis
St. Paul, MN: Minnesota Department of Health; March 2019.
The National Quality Forum has defined 29 never events—patient safety problems that should never occur, such as wrong-site surgery and patient falls. Since 2003, Minnesota hospitals have been required to report such incidents. The 2018 report summarizes information about 384 adverse events that were reported and found pressure ulcers and invasive procedure events increased, while fall-related deaths decreased. Reports from previous years are also available.
Hatch S. New York, NY: Basic Books; 2016. ISBN: 9780465050642.
Journal Article > Commentary
Donaldson LJ. BMJ Qual Saf. 2015;24:603-604.
Narrative elements of care failures can help motivate commitment to patient safety work by placing the incident in context. Exploring the value of patient perspectives associated with adverse events, this commentary suggests that improvement leaders consider the patient experience when designing harm reduction efforts.
Journal Article > Study
Etchegaray JM, Ottosen MJ, Burress L, et al. Health Aff (Millwood). 2014;33:46-52.
Patient engagement is increasingly recognized as a key element for patient safety. Although patients and family members may provide unique insights into adverse events, they are rarely asked to participate in medical error investigations, such as root cause analyses. Using detailed interviews, this study revealed that clinicians and hospital administrators generally support including patients and family members in these types of activities, but they are not sure how best to do so. A group of patients and health care experts at a national conference explored these findings and felt that patient involvement was desirable, but they identified many concerns and limitations with this approach. A recent AHRQ WebM&M perspective by Dr. Saul Weingart discussed the opportunities for patient engagement in patient safety.
Award > Award Recipient
Apold J, Daniels T, Sonneborn M. Jt Comm J Qual Patient Saf. 2006;32:672-675.
This article discusses the efforts of the Minnesota Alliance for Patient Safety to promote a culture of safety among the state's health care organizations.
Holt TE. Men's Health. November 3, 2006.
This series includes articles on "doorway diagnosis" (or a doctor's assessment of a patient before an exam begins), anesthesiologists addicted to painkillers, and medical mistakes in the emergency room.
Journal Article > Study
Cohn F, Rudman WJ. Jt Comm J Qual Saf. 2004;30:636-646.
Berntsen KJ. Westport, CT: Praeger; 2004. ISBN: 0275982300.
The author provides an introduction to issues affecting safety in health care for a consumer audience. The text is interspersed with relevant stories from patients and tips to minimize opportunities for failure.
Cullen A. Uitgeverij van Brug: The Hague, The Netherlands; 2019. ISBN: 9789065232236.
Patient stories offer important insights regarding the impact medical errors have on patients and their families. This book shares the author's experience with medical error and spotlights how lack of transparency in European health care can contribute to avoidable process failures that result in patient harm.
Journal Article > Study
Jalal H, Buchanich JM, Roberts MS, Balmert LC, Zhang K, Burke DS. Science. 2018;361:1184.
Opioid overdose deaths remain a threat to patient safety. Information about how overdose deaths are nationally distributed is critical to inform prevention efforts. This robust analysis examined all drug overdose deaths in the United States over a 38-year period. Drug overdoses began increasing exponentially long before the opioid prescribing boom in the mid-1990s and continue to rise in this way. Demographically distinct subepidemics of prescription opioid, synthetic opioid, and stimulant use all contribute to drug overdose deaths as a whole. The authors speculate about what factors other than opioid prescribing might drive escalating substance use-related deaths. An Annual Perspective and a PSNet perspective provide further insights into how safety efforts can reduce opioid-related harm.
Young A, Kelly J, Schnaars C, Ungar L. USA Today.
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.
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.
Boodman SG. Washington Post. December 9, 2017.
The prevalence of polypharmacy among older patients represents an important concern for health care safety, as unneeded medications can contribute to patient harm. This newspaper article reports on several strategies to reduce inappropriate medication use in older patients, including desprescribing and brown bag medication review.
Journal Article > Study
Ringdal M, Chaboyer W, Ulin K, Bucknall T, Oxelmark L. BMC Nurs. 2017;16:69.
This qualitative study of hospitalized patients in Sweden found that patients expressed interest in engaging in their care. Themes included shared decision-making and increasing patient understanding of health conditions. Patients also expressed concern about the power dynamic between patients and providers and uncertainty about how to best participate in their own hospital care.
William Brangham. PBS News Hour. September 29, 2017.
Hobson K. Health Shots. National Public Radio. September 8, 2017.
Medication regimen nonadherence can result in patient harm. This news article reports the results of a national poll, which found that a substantial number of patients under the age of 35 do not take their medication as directed. Patients who stopped taking medications without consulting their doctors cited various reasons, including forgetfulness, feeling better, and belief the medication did not work .
Mickle K. Glamour Magazine. August 11, 2017.
Kowalczyk L. Boston Globe. July 29, 2017.
Landi H. Healthcare Informatics. June 1, 2017.
The use of copy and paste is a popular time-saving mechanism to update electronic medical documentation, but this practice can introduce risks. This news article reports on various resources that explore problems associated with the copying and pasting in electronic health records, including a recent study that highlighted how this practice can perpetuate incomplete or wrong information into patient records.