Narrow Results Clear All
- Study 2
- Legislation/Regulation 1
- Newspaper/Magazine Article
- Special or Theme Issue 12
- Toolkit 1
- Web Resource 25
- Award 3
Communication between Providers
- Sbar 2
- Communication between Providers 115
- Culture of Safety 75
Education and Training
- Simulators 13
- Students 6
Error Reporting and Analysis
- Error Reporting 133
Human Factors Engineering
- Checklists 37
Legal and Policy Approaches
- Regulation 26
- Logistical Approaches 41
- Policies and Operations 9
Quality Improvement Strategies
- Benchmarking 11
- Specialization of Care 35
- Teamwork 37
- Clinical Information Systems 78
- Transparency and Accountability 16
- Alert fatigue 3
- Device-related Complications 51
- Diagnostic Errors 94
- Discontinuities, Gaps, and Hand-Off Problems 74
- Drug shortages 10
- Failure to rescue 3
- Fatigue and Sleep Deprivation 13
- Identification Errors 40
- Interruptions and distractions 8
- Delirium 1
- Medication Errors/Preventable Adverse Drug Events 164
- MRI safety 4
- Nonsurgical Procedural Complications 20
- Overtreatment 5
- Psychological and Social Complications 61
- Second victims 8
- Surgical Complications 138
- Transfusion Complications 4
- Ambulatory Care 73
- Operating Room 100
- General Hospitals 194
- Long-Term Care 14
- Outpatient Surgery 17
- Patient Transport 7
- Psychiatric Facilities 4
- Allied Health Services 2
- Geriatrics 21
- Obstetrics 24
- Pediatrics 52
- Primary Care 12
- Radiology 21
- Internal Medicine 312
- Nursing 35
- Pharmacy 74
- Family Members and Caregivers 25
- Health Care Executives and Administrators 410
Health Care Providers
- Nurses 47
- Pharmacists 20
- Physicians 131
Non-Health Care Professionals
- Educators 26
- Engineers 26
- Media 3
- Patients 409
- Europe 25
- Canada 8
United States of America
United States Federal Government
- Department of Health and Human Services (HHS) 19
- United States Federal Government 24
Search results for "Medicine"
- Newspaper/Magazine Article
Hoenig LJ. Med Econ. 2006 Jun 2;83:45-46.
The author discusses the importance of thorough discharge examinations.
Santell JP. Drug Topics (Health-System Edition). May 22, 2006.
This article reports on errors involving neuromuscular blocking agents (NMBAs) that were reported to Medmarx database, what factors contributed to those errors, and what can be done to minimize their occurrence.
van der Grinten P. Patient Safety & Quality Healthcare. May/June 2006;3:46-48.
This article reports on how regional health information organizations (RHIOs) increase access to patient information and benefit patient safety.
Zaidi K, Curry PD Jr, Becker SC. Pharmaceutical Technology. November 2, 2005;29:102-103.
This article reports on recommendations developed by United States Pharmacopeia (USP) to improve the safety of using medical gas, including revisions to USP monographs.
Joseph R, Harry E. Medical Economics. June 27, 2019.
Multitasking can negatively affect cognitive load and diminish safety. This magazine article reports on how multitasking can contribute to surgeon fatigue, burnout, and decreased task completion in the perioperative environment. Checklists to automate workflow and limiting the number of patient charts that can be open at one time can help reduce extraneous cognitive load.
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.
Palmer J. Patient Saf Qual Healthc. May/June 2019.
Organizations must learn from adverse events to prevent similar incidents. Reporting on lessons to be learned from the cascade of failures connected with the preventable death of a patient during an acute asthma attack at the door of a hospital emergency department, this magazine article outlines the importance of effective signage, appropriate security staff placement, and acceptance of the responsibility for failure.
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.
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.
Field C, Finley E, Deutsch ES. PA-PSRS Pa Patient Saf Advis. 2019;16(1).
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.