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- Communication Improvement 4
- Culture of Safety 2
- Education and Training 2
- Error Reporting and Analysis 2
- Human Factors Engineering 1
- Legal and Policy Approaches
- Quality Improvement Strategies 1
- Technologic Approaches 2
- Diagnostic Errors 1
- Discontinuities, Gaps, and Hand-Off Problems 2
- Identification Errors 1
- Medical Complications 2
- Medication Safety 5
- Overtreatment 1
- Surgical Complications 2
- Transfusion Complications 1
Search results for "Latent Errors"
- Latent Errors
Baltimore, MD: Centers for Medicare & Medicaid Services (CMS) Office of Public Affairs; May 18, 2006.
This fact sheet provides information regarding the Centers for Medicare and Medicaid Services' initiative to better understand and minimize never events.
Journal Article > Commentary
Judson TJ, Press MJ, Detsky AS. Healthc (Amst.). 2019;7:4-6.
Health care is working to provide high-value care and prevent overuse while ensuring patient safety. This commentary highlights the importance of educational initiatives, mentors, and use of clinical decision support to help clinicians determine what amount of care is appropriate for a given clinical situation.
Jt Comm J Qual Patient Saf. 2016;42:243-264.
Journal Article > Study
Kozhimannil KB, Sommerness SA, Rauk P, et al. Jt Comm J Qual Patient Saf. 2013;39:339-348.
An inconvenient truth about the patient safety movement is that in many cases hospitals actually profit when errors occur. A recent study found that hospitals received greater net reimbursements for patients who experienced surgical complications compared with patients whose surgeries were uncomplicated. This study examined the financial impact of an effort to eliminate obstetric complications in a five-hospital health system. The project led to an 11% reduction in preventable adverse events, but hospital reimbursements decreased considerably as a result—meaning that although costs were saved, the hospitals' net revenues declined overall. This finding represents a classic case of misaligned incentives: the outcome was beneficial for payers and patients (who received higher quality care at lower cost) but not directly beneficial for hospitals (who shouldered the cost of implementing the intervention but lost revenue as a result). As the return on investment for safety interventions such as computerized provider order entry is marginal at best, payment system reform to align incentives will be necessary in order to improve the business case for safety.
Hospira Carpuject pre-filled cartridges—drug alert: products may contain more than the intended fill volume.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; May 23, 2012.
This announcement raises awareness of pre-filled medication cartridges that may be overfilled, thereby increasing the risk of overdose. The FDA recommends that practitioners confirm the dosage prior to dispensing and administering the medication.
Journal Article > Review
Yuen JK, Reid MC, Fetters MD. J Gen Intern Med. 2011;26:791-797.
The review reveals shortcomings associated with do-not-resuscitate orders and suggests strategies to improve communication and hospital culture.
Journal Article > Study
Sharif I, Tse J. Pediatrics. 2010;125:960-965.
Misunderstanding prescription drug labels is a recognized source of errors in ambulatory care. Low health literacy places patients at higher risk, and language barriers may also contribute to preventable medication errors, as illustrated vividly in an AHRQ WebM&M commentary. A prior study found that translated drug labels are available in many pharmacies, but this study found that Spanish-language labels generated by commercial translation systems are disturbingly inaccurate. Half of the labels contained at least one error, and the authors document examples of incomplete or inaccurate translations that could lead to serious patient harm (for example, "once a day" mistranslated as "eleven times per day"). A prior study also found that Spanish-speaking patients may be at higher risk of experiencing errors while hospitalized.
Perspectives on Safety > Interview
The Role of the Media in Patient Safety, October 2009
Charles Ornstein is a senior reporter at ProPublica, a nonprofit news organization in New York. Formerly with the Los Angeles Times, he co-wrote a series of articles about medical errors at Martin Luther King Jr./Drew Medical Center, which closed in 2007; the series earned the newspaper a Pulitzer Prize for Public Service. He is also the president of the Association of Health Care Journalists. We asked him to speak with us about the role of the media in patient safety. This interview was conducted while he was still at the Times.
Journal Article > Study
Beyond our walls: impact of patient and provider coordination across the continuum on outcomes for surgical patients.
Weinberg DB, Gittell JH, Lusenhop RW, Kautz CM, Wright J. Health Serv Res. 2007;42:7-24.
The investigators surveyed patients regarding the coordination of their postdischarge care and identified problems with coordination across settings, within settings, and between patients and providers.
The Medication Errors Panel. Sacramento, CA: California State Senate; March 2007.
This report shares findings from an expert panel convened to study the causes of medication error in the outpatient setting and provide recommendations for reducing errors associated with prescription and over-the-counter medications.
ISMP Medication Safety Alert! Acute Care Edition. September 21, 2006;11:1-2.
This second part of this series discusses the three types of behavior involved in error—human error, at-risk behavior, and reckless behavior—including causes of each and appropriate responses.