Narrow Results Clear All
- Communication between Providers 24
- Culture of Safety 14
Education and Training
- Students 4
Error Reporting and Analysis
- Error Reporting 44
Human Factors Engineering
- Checklists 13
- Legal and Policy Approaches 65
- Logistical Approaches 11
- Policies and Operations 5
- Quality Improvement Strategies 42
- Specialization of Care 7
- Teamwork 7
- Clinical Information Systems 20
- Transparency and Accountability 5
- Alert fatigue 3
- Device-related Complications 10
- Diagnostic Errors 28
- Discontinuities, Gaps, and Hand-Off Problems 14
- Drug shortages 4
- Failure to rescue 1
- Fatigue and Sleep Deprivation 3
- Identification Errors 7
- Interruptions and distractions 1
- Delirium 1
- Medication Errors/Preventable Adverse Drug Events 53
- Nonsurgical Procedural Complications 2
- Overtreatment 3
- Psychological and Social Complications 26
- Second victims 4
- Surgical Complications 27
- Transfusion Complications 1
- Ambulatory Care 38
- General Hospitals 40
- Long-Term Care 6
- Outpatient Surgery 5
- Psychiatric Facilities 1
- Allied Health Services 2
- Dentistry 1
- Geriatrics 11
- Internal Medicine 62
- Nursing 14
- Pharmacy 30
- Family Members and Caregivers 10
- Health Care Executives and Administrators 110
Health Care Providers
- Nurses 20
- Pharmacists 15
- Physicians 37
Non-Health Care Professionals
- Media 2
- Patients 133
- Europe 7
- Canada 3
United States of America
United States Federal Government
- Department of Health and Human Services (HHS) 10
- United States Federal Government 12
Search results for "Epidemiology of Errors and Adverse Events"
- Newspaper/Magazine Article
- Epidemiology of Errors and Adverse Events
Tozzi J. Bloomberg News Service. June 10, 2016.
CDC Vital Signs. March 3, 2016.
Health care–associated infections (HAI) are a worldwide patient safety problem. This article and accompanying set of infographics spotlight the importance of addressing HAIs and provide updates on improvements associated with better use of catheters, appropriate patient isolation, and increased vigilance to reduce the risks of antibiotic-resistant infections.
Luthra S. Kaiser Health News. July 14, 2015.
Butcher L. Trustee Magazine. June 8, 2015.
Board member and health care executive commitment is important for establishing a culture of safety. This magazine article features insights from hospital leaders that have achieved success in their organizations' adoption of safety culture through engaging leadership, setting goals, and incorporating high-reliability principles.
Ungar L. USA Today. February 1, 2015.
24-Hour inpatient pulse oximetry monitoring reduces rescue events and intensive care unit transfers.
Agency for Healthcare Research and Quality. Health Care Innovations Exchange. June 18, 2014.
Effective monitoring can enable early detection of deteriorating patients while reducing nuisance alarms. Relating how one hospital implemented round-the-clock monitoring and adjusted alarm thresholds, this article reports results of the program such as fewer patient transfers to the intensive care unit and no subsequent adverse events.
Is your hospital really as safe as you think? Our updated hospital safety score can help you find out.
Consumer Reports. March 27, 2014.
Despite lack of consensus on the value of comparative hospital safety scores, they continue to generate interest and discussion around safety improvement efforts. This news article reports one analysis of patient safety in United States hospitals using five federal measures of safety: mortality, readmission, computed tomography scanning, hospital-acquired infections, and communication regarding medications and discharge planning.
McLeod M, Barber N, Franklin BD. National Quality Measures Clearinghouse: Expert Commentaries; March 10, 2014.
Strategies to prevent medication errors are an ongoing focus in patient safety. This expert commentary discusses challenges associated with tracking medication administration failures and recommends regular monitoring of medication delivery practices to avoid errors.
Consumer Reports. September 2013;78:31-41.
This report analyzed Medicare claims data on 27 types of procedures to develop surgical safety ratings of hospitals by state.
Kershaw S. New York Times. Sepember 7, 2007;Metro Desk section:B1.
This article reports on an initiative to publish data on mortality and hospital-acquired infections in New York City public hospitals.
Baertlein L. USA Today. May 24, 2006.
This article reports on a study that found that playing video games before surgery enhanced surgical dexterity and minimized errors.
Quick Safety. July 15, 2019;(50):1-4.
This newsletter article discusses nurse burnout and how to reduce conditions that contribute to the problem. Recommendations focus on the role of leadership in fostering resilience, organizational strategies to enhance nurse empowerment, and frontline learning and regular measurement of staff perceptions of their well-being at work.
Colino S. Fam Circle. August 2019;132:66,69.
Patients and families can play a role in ensuring care is effective and safe. This news article recommends ways for patients to reduce risk of errors during a hospitalization, including using a patient portal to identify mistakes, asking questions, bringing an advocate, and working with hospitalists as key care partners.
Appleby J, Lucas E. Kaiser Health News. June 21, 2019.
ISMP Medication Safety Alert! Acute Care Edition. June 6, 2019;24.
Butcher L. Managed Care. June 2019;28:37-39.
Inconsistent patient name entry practices in electronic health records can contribute to wrong-patient errors. This magazine article reports on the complex nature of addressing patient-matching discrepancies as an economic, privacy, and technical problem. Improvement strategies include the development and adoption of a national identification program and biometric technology. A WebM&M commentary discussed problems associated with name similarities in the electronic patient record.
Gabler E. New York Times. May 31, 2019.
Pediatric cardiac surgery is highly technical and risky. This newspaper article reports on a poorly performing pediatric cardiac surgery program, concerns raised by staff, and insufficient response from organizational leadership. Lack of data transparency, insufficient resources, and limited program capabilities to support a complex program contributed to poor outcomes for pediatric patients.
Hilton K, Anderson A. Harv Bus Rev. May 20, 2019.
This commentary describes how one health system worked to combat resistance to change associated with implementation of a checklist initiative. The success of the program was built on empowering team members to drive the process, clinician motivation to provide safe care, and engaging leadership. A PSNet interview with Lucian Leape discussed surgical safety checklists.
Ross C. STAT. May 13, 2019.
Nuisance alarms, interruptions, and insufficient staff availability can hinder effective monitoring and response to acute patient deterioration. This news article reports on how hospital logistics centers are working toward utilizing artificial intelligence to improve clinician response to alarms by proactively identifying hospitalized patients at the highest risk for heart failure to trigger emergency response teams when their condition rapidly declines.
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.
Frakt A. New York Times. April 29, 2019.
Health care providers are a known source of potentially harmful bacteria due to their perpetual interaction with germs during practice. This newspaper article reports on how clinician attire, stethoscopes, and technology can be contaminated with bacteria. Hand sanitizer placement, sleeve length, and laundering behaviors can reduce transmission of pathogens.
ISMP Medication Safety Alert! Acute Care Edition. April 25, 2019.
Newborns assigned temporary names are at increased risk for patient misidentification and wrong-patient errors. This newsletter article reports on the role of electronic health records in newborn misidentification and the unintended consequences associated with a Joint Commission set of recommendations to reduce risk.
Cheney C. HealthLeaders Media. April 17, 2019.
This news article describes how a 19-hospital health system successfully applied high reliability principles to emphasize a zero-tolerance focus on patient harm. The coordinated effort across the system achieved a drop in readmissions and physician burnout. Tactics used to improve reliability include huddles, purposeful redundancy, and leadership engagement.
Field C, Finley E, Deutsch ES. PA-PSRS Pa Patient Saf Advis. 2019;16(1).
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.
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.
Beck DL. ASH Clinical News. December 1, 2018.
Wild D. Pharmacy Practice News. November 8, 2018.
Medication safety officers serve as organizational champions of medication management process improvement. This news article offers two examples of health care organizations that positioned medication safety officers as leaders in their systems. The piece describes improvements stemming from employment of medication safety officers at these organizations.
ISMP Medication Safety Alert! Acute Care Edition. November 1, 2018;23:1-5. November 15, 2018;23:1-5.
Errors in the administration of intravenous medications can result in patient harm. This set of articles discusses the results of a nationwide IV push medication survey. The first article reviews unsafe practices in care delivery as defined by inpatient clinicians. The second article recommends ways to improve practice such as assessment of current practices, use of prefilled syringes, and heightened attention to effective labeling.
Gipson K. PA-PSRS Pa Patient Saf Advis. 2018 Oct 31;15(suppl 1):39-45.
van der Heijde R, Deichmann D. Harv Bus Rev. October 30, 2018.
Aviation continues to provide inspiration for patient safety innovation. This commentary describes a 10-minute team huddle exercise which involves team members rating their own mood status and the leader asking if there are any contextual concerns. In addition, two team members select "knowledge cards" that either test the person's knowledge or assign the person to proactively watch for improvement opportunities during the shift. The results encouraged sharing, situational awareness, and team building.
Kaiser Health News.
Peeples L. Pharmacy Practice News. October 10, 2018.
Structured handoffs can reduce communication problems that contribute to medical error. This magazine article reports on how I-PASS implementation can help enhance the quality and completeness of handoffs, highlights the need for pharmacists to be more engaged in handoff improvement, and offers insights for enhancing their role in the process. In a past PSNet interview, Dr. Amy Starmer discussed the implementation and findings of the landmark I-PASS study.
Peskin SM. New York Times. October 4, 2018.
Error disclosures are difficult but important conversations that can have negative consequences for patients, clinicians, and organizations, even when they are done appropriately. This newspaper article offers insights from a doctor who experienced both sides of disclosure, as a physician disclosing an error and as a patient whose physician missed a complication, and discusses how to manage relationships once clinical mistakes are recognized.
Liberatore K. PA-PSRS Patient Saf Advis. 2018;15(3).
Engaging patients and families in patient safety efforts is a key priority in health care. This poll of patients from Pennsylvania explores actions patients are likely to take to ensure their safe care. The results indicate a strong willingness to ask questions to help patients better understand their care, but patients were uncomfortable with raising concerns if they saw clinician behaviors that diminish safety, such as lack of hand hygiene compliance.
Sederstrom J. Drug Topics. September 17, 2018.
Medication errors continue to be a worldwide patient safety challenge that requires both systems and individual practice strategies for improvement. This magazine article describes how pharmacists can address failures associated with processing, dosing, care transitions, and information sharing to prevent medication errors.
Decerbo M. Pharmacy Practice News. September 13, 2018.
Parenteral nutrition errors can result in patient malnutrition and harm. Reporting on how insufficient understanding of malnutrition contributes to its presence in health care, this news article suggests that both general guidelines and tailored approaches to nutrition are necessary to keep hospitalized patients safe. Improvements in addressing the complicated needs of patients who are older or have cancer illustrate progress made toward the effective delivery of nutrition.
Eldred SM. Health Shots. National Public Radio. August 15, 2018.
Using professional interpreters can avert risks of miscommunication due to language barriers between patients and clinicians. This news article discusses how lack of qualified medical interpreters, use of ad hoc interpreters, and poor patient understanding of instructions can contribute to adverse events. A WebM&M commentary explored patient safety issues associated with patient–clinician language differences.
Fetters A. The Atlantic. August 10, 2018.
Women face implicit bias that can affect the safety and effectiveness of their care. Reviewing several high-profile accounts that raised awareness of challenges women experience in health care, this magazine article describes challenges to safe care such as lack of physician attention to patient concerns, misdiagnosis, and preconceptions regarding pain intensity.
Jewett C, Alesia M. Kaiser Health News. August 9, 2018.
High-profile failures during office-based procedures have raised awareness of the potential safety hazards of surgery centers and the need for improved oversight. This news article reports on safety events in ambulatory surgical centers and insufficiencies in incident reporting and analysis. Enhanced transparency regarding those failures can enable informed patient decision-making when choosing care providers.
Young A, Kelly J, Schnaars C, Ungar L. USA Today.
Students have a key role in a culture of safety: analysis of student-associated medication incidents.
ISMP Medication Safety Alert! Acute Care Edition. July 26, 2018;23:1-4.
Previous studies have discussed concerns associated with new clinician involvement in care delivery. This data analysis highlights how organizational culture affects student-related errors and summarizes the positive contribution students bring to medication safety, including new perspectives, recently acquired evidence, and a willingness to ask questions.
ISMP Medication Safety Alert! Acute Care. July 12, 2018;23:1-4.
Smart pumps are employed throughout health care, but their design can challenge safety. Reporting results of a national survey, this newsletter article outlines how smart pump data is being used to improve compliance and suggests ways organizations can enhance the value of analytics to inform frontline practice improvement. A previous WebM&M commentary discussed a smart infusion pump error that resulted in patient harm.
Bruley ME, Arnold TV, Finley E, Deutsch ES, Treadwell JR. PA-PSRS Pa Patient Saf Advis. June 2018;15.
Although surgical fires are considered never events, they continue to occur. This article reports findings from an analysis of 28 operating room fire incidents submitted over a 5-year period to the Pennsylvania Patient Safety Reporting System. Although incidence of surgical fires has significantly decreased since earlier reporting periods, half of the reported events resulted in patient harm. A past WebM&M commentary discussed surgical fires and how to prevent them.
Gale SF. Chief Learning Officer. July/August 2018;17:22-25.
Hoffman RM, Mirarchi FL. PA-PSRS Patient Saf Advis. June 2018;15.
Patient harm associated with advance directive interpretation errors is rare, but these mistakes can have negative psychological consequences for care teams, patients, and families. Discussing research exploring factors that contribute to these misunderstandings, this article recommends actions to help patients articulate end-of-life care preferences and ensure those instructions are accurately shared with their families and the clinical teams acting on their behalf.
ISMP Medication Safety Alert! Acute Care Edition. June 14, 2018,23:1-5. June 28, 2018;23:1-4,6,7.
Mistakes in the use of vaccines can have both individual and public health implications. The first article of this series reviews the results from an analysis of reports submitted to a national error reporting system to track vaccine-related errors. The second article offers recommendations to help immunization and vaccination programs address product-, knowledge-, and practice-related factors that contribute to process weaknesses, including training, storage, and labeling strategies.
Rau J. Kaiser Health News. June 13, 2018.
Safety problems are common in nursing homes due to challenges such as poor safety culture, staff burnout, and inappropriate polypharmacy. Describing how medication missteps and communication errors can diminish safety of residential care, this news article discusses system-level incentives that can either contribute to avoidable hospital readmissions of long-term care patients or be employed to improve practice.
The Economist. June 7, 2018.
Artificial intelligence (AI) can improve the timeliness and accuracy of decision making in health care. This magazine article reports on how AI use in medicine can affect diagnosis of cancers, stroke, and cardiac arrhythmia. The piece underscores that though these improvements may look impressive, human knowledge will still be necessary to achieve the full benefit of AI applications for health care improvement.