Narrow Results Clear All
- WebM&M Cases 3
- Perspectives on Safety 1
- Review 2
- Study 14
- Slideset 1
- Book/Report 34
- Legislation/Regulation 2
- Newspaper/Magazine Article 137
- Toolkit 3
- Web Resource 31
- Grant 1
- Press Release/Announcement 4
- Communication Improvement 55
- Culture of Safety 14
Education and Training
- Students 1
Error Reporting and Analysis
- Error Reporting 52
- Human Factors Engineering 26
Legal and Policy Approaches
- Regulation 11
- Logistical Approaches 15
- Policies and Operations 2
Quality Improvement Strategies
- Benchmarking 11
- Specialization of Care 8
- Teamwork 5
- Clinical Information Systems 9
- Transparency and Accountability 7
- Device-related Complications 17
- Diagnostic Errors 32
- Discontinuities, Gaps, and Hand-Off Problems 21
- Drug shortages 3
- Failure to rescue 1
- Fatigue and Sleep Deprivation 4
- Identification Errors 5
- Interruptions and distractions 1
- Medical Complications 65
- Medication Errors/Preventable Adverse Drug Events 25
- Nonsurgical Procedural Complications 4
- Overtreatment 1
- Psychological and Social Complications 11
- Surgical Complications 31
- Transfusion Complications 3
- Ambulatory Care 21
- General Hospitals 29
- Long-Term Care 9
- Outpatient Surgery 1
- Psychiatric Facilities 1
- Allied Health Services 1
- Geriatrics 20
- Pediatrics 10
- Internal Medicine
- Nursing 8
- Palliative Care 2
- Pharmacy 10
- Family Members and Caregivers 24
- Health Care Executives and Administrators 62
Health Care Providers
- Nurses 3
- Physicians 20
Non-Health Care Professionals
- Media 6
- Australia and New Zealand 1
- Europe 20
- Canada 7
- United States of America 208
Search results for "Patients"
- Internal Medicine
Sun LH. The Washington Post. October 13, 2016.
Medical devices can contribute to the spread of health care–associated infections. This news article discusses a government report that raises concerns that patients may have been exposed to a deadly bacterial infection related to an essential piece of equipment used in cardiac surgery worldwide. The resulting infection can be difficult to diagnosis as symptoms may remain dormant for months after the initial exposure.
Shell ER. Sci Am. 2015;313(5):28-29.
Daley J. Colorado Public Radio. February 17, 2015.
Patient and family stories of harm are increasingly promoted as a strategy to provide insights into medical errors. This radio segment interviews a patient advocate whose daughter died due to medical errors, including failure-to-rescue and a health care–associated infection, and who speaks about that experience to educate clinicians on the importance of patient safety and listening to patients' families.
Jaffe I, Renincasa R. Morning Edition. National Public Radio. December 8–9, 2014.
Overprescribing of medications is a common problem in nursing homes. This two-part radio segment reports on the inappropriate use of antipsychotic medications as a chemical restraint for patients with dementia. The first part introduces the issue and includes insights from families that have experienced harm due to the practice. The second segment discusses programs that the Centers for Medicare and Medicaid Services has put in place to address the problem through a more patient-centered approach to care and suggests strengthening penalties against organizations that overuse antipsychotics.
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.
Journal Article > Review
Promoting engagement by patients and families to reduce adverse events in acute care settings: a systematic review.
Berger Z, Flickinger TE, Pfoh E, Martinez KA, Dy SM. BMJ Qual Saf. 2014;23:548-555.
Patient engagement is touted as an important tool for detecting adverse events and ensuring safety. This systematic review found that more high-quality evidence is needed to inform practical application of patient engagement programs.
Harrow, Middlesex, UK: The Patients Association; 2013.
This publication provides patient and family accounts of incidents involving inadequate care or harm and highlights the need for improvements recommended in a National Health Services report.
Tools/Toolkit > Multi-use Website
Rockville, MD: Agency for Healthcare Research and Quality; June 2013.
Studies have shown that a surprisingly large proportion of hospitalized patients are not aware of their diagnoses or treatment plan and that their preferences are often not taken into account in advanced care planning. This failure to provide patient-centered care indicates a need for increased patient engagement in safety and quality efforts. This toolkit published by the Agency for Healthcare Research and Quality is designed to help hospitals develop partnerships with patients around improving safety. Developed with input from clinicians and patients, the guide emphasizes four strategies—working with patients as advisors, improving bedside communication, integrating patients and families into shift changes, and using patient input to improve the discharge process. An AHRQ WebM&M perspective by Dr. Saul Weingart discusses the practical challenges of engaging patients in improvement efforts.
Web Resource > Multi-use Website
Global Sepsis Alliance.
Teegardin C. Atlanta Journal-Constitution. April 28, 2013.
Journal Article > Commentary
Petronio S, Torke A, Bosslet G, Isenberg S, Wocial L, Helft PR. Perm J. 2013;17:73-79.
This piece describes a two-step model to help physicians disclose medical errors to patients and families.
Journal Article > Study
Pinto A, Faiz O, Vincent C. BMJ Qual Saf. 2012;21:1001-1008.
This study explored current practices related to the National Health Services' being open policy for communicating unintentional harm with patients and families.
Pear R. New York Times. September 23, 2012:A20.
The newspaper article discusses a proposed federal initiative for patients and families to report experiences with medical errors.
Makary M. New York, NY: Bloomsbury Press; 2012. ISBN: 9781608198368.
Nance JJ, Bartholomew KM. Boseman, MT: Second River Healthcare Press; 2012. ISBN: 9781936406128.
Web Resource > Multi-use Website
Drawing from data reported by the Leapfrog Hospital Survey, the Agency for Healthcare Research and Quality (AHRQ), the Centers for Disease Control and Prevention (CDC), and the Centers for Medicare and Medicaid Services (CMS), this website provides grades for hospitals in the United States based on their safety. The 2018 results are the sixth generation of the scores, which now include a medication error score. A related report from the Armstrong Institute examines avoidable death associated with grading hospitals.
Trew M, Nettleton S, Flemons W. Edmonton, AB, Canada: Canadian Patient Safety Institute; June 2012.
This publication describes an investigation into engaging with patients and families that have been harmed and recommends best practices for organizations to enable such collaboration.
Golden, CO: HealthGrades Inc.; May 2012.
This report used Medicare hospitalization data from 2008–2010 to explore correlations between patient–provider communication and patient safety in high-performing hospitals in the United States.
Sanders L. New York Times Magazine. March 18, 2012.
This interactive magazine feature takes readers through the decision-making process in a case involving diagnostic error.