Narrow Results Clear All
- Communication Improvement 15
- Culture of Safety 5
- Education and Training 6
- Error Reporting and Analysis 14
- Human Factors Engineering 3
- Legal and Policy Approaches 2
- Logistical Approaches 2
- Quality Improvement Strategies 6
- Specialization of Care 1
- Teamwork 1
- Technologic Approaches 6
- Transparency and Accountability 1
- Diagnostic Errors 2
- Discontinuities, Gaps, and Hand-Off Problems 1
- Identification Errors 1
- Medical Complications 2
- Medication Safety 4
- Psychological and Social Complications 7
- Surgical Complications 3
- Family Members and Caregivers 4
- Health Care Executives and Administrators 15
Health Care Providers
- Nurses 3
Non-Health Care Professionals
- Media 1
Search results for "Patients"
Journal Article > Study
A patient-initiated voluntary online survey of adverse medical events: the perspective of 696 injured patients and families.
Southwick FS, Cranley NM, Hallisy JA. BMJ Qual Saf. 2015;24:620-629.
This study analyzed data from an internet-based reporting system that enabled patients and families to describe adverse events. Respondents reported missed and delayed diagnoses, treatment errors, procedural complications, health care–associated infections, and adverse drug events. Most participants did not experience prompt error disclosure but instead faced a denial of responsibility and secretive behavior, which they related to subsequent mistrust. To prevent adverse events, patients and family members suggested using systems approaches (such as universal handwashing and other infection control measures), improving care transitions between providers, ensuring supervision of trainees, and partnering with patients and families for shared decision-making. These findings underscore the importance of error disclosure, effective communication, and allowing patients to report adverse events in order to enhance safety.
NPSF Lucian Leape Institute Roundtable on Consumer Engagement in Patient Safety. Boston, MA: National Patient Safety Foundation; March 2014.
The National Patient Safety Foundation's Lucian Leape Institute recently convened two roundtables to discuss engaging patients and families in improving patient safety. This report describes the current landscape of patient engagement efforts, along with the potential benefits and challenges. To facilitate more productive partnerships in ensuring safety, the group provides recommendations and checklists for health care leaders, clinicians, patients, families, and policymakers. They advocate for patients to be equal partners in organizational and clinician care improvement activities. Patients are encouraged to feel empowered to ask questions and to actively participate in their care plans. A recent AHRQ WebM&M perspective explores the role of patient engagement in safety.
The Empowered Patient Coalition; 2010.
This video series uses two real cases of patients who died due to preventable errors after elective surgery to illustrate fundamental concepts in patient safety and provide lessons for patients and families in engaging in their own care. The circumstances leading to the death of Lewis Blackman, one of the patients discussed in this video series, are discussed in more detail in a separate article that analyzes his death as an example of failure to rescue.
Partnering with Patients and Families to Design a Patient- and Family-Centered Health Care System: Recommendations and Promising Practices.
Johnson B, Abraham M, Conway J, et al. Bethesda, MD: Institute for Family-Centered Care; April 2008.
This report summarizes results from a conference of consumers, health care professionals, and administrative leaders about improving the health care system and advancing patient-centered care. Key recommendations include involving patients and families in health care leadership, through measures such as patient advisory councils and partnering with community organizations. The report also emphasizes the role of health literacy in providing patient-centered care.
Bosk CL. Chicago, IL: University of Chicago Press; 2003. ISBN: 0226066789.
In this seminal study, Bosk, a medical sociologist at the University of Pennsylvania, spent a year observing the surgical residents and faculty at an unnamed hospital, in the process exploring the balance between autonomy and oversight in medical training, how physicians deal with their errors, and the nature of accountability in the medical profession. This edition, published more than two decades after Forgive and Remember was first published, includes a new prologue, epilogue, and list of appendices. The book is informative for both lay readers and clinicians.
Wall of Silence: The Untold Story of the Medical Mistakes That Kill and Injure Millions of Americans.
Gibson R, Singh JP. Washington, DC: Lifeline; 2003. ISBN: 089256112X.
Written by a program officer at the Robert Wood Johnson Foundation and a health economist, this book chronicles real stories of victims of medical mistakes. Written in a popular style and in an advocate's tone, experts may find the analyses of individual errors and discussion of policy implications a bit superficial; the book's major contribution is putting a human face on medical errors.
Berwick DM. New York, NY: The Commonwealth Fund; 2002.
This report represents an edited version of Donald Berwick's Plenary Address presented at the Institute for Healthcare Improvement's 11th Annual National Forum on Quality Improvement in Health Care (December 1999). In his address to more than 3000 attendees, Berwick uses the story of the Mann Gulch Fire tragedy to frame a series of reflections on the failures of systems, organizations, and individuals who operate within them. He goes on to share his personal experience with the health care system in describing the details of his wife's illness that required several hospitalizations, placing him at the sharp end to experience our system's shortcomings on a daily basis. He builds on the anecdotes by describing factors that contribute to an organization's failures, once again incorporating a number of analogies that make his delivery of content easy to grasp for novices and experts in the audience. Finally, Berwick proposes three design elements in creating a radically different and much improved health care system. They include greater access for patients to the system, improved application of science at the bedside, and better attention to the interactions between patients and the system.
Gawande A. New York, NY: Metropolitan Books; 2002. ISBN: 0805063196.
In Complications, Gawande reprises and builds on a series of feature articles, several written for the New Yorker during his surgical residency at Harvard, exploring the imperfect science of medicine. Part I, Fallibility, explores several patient safety issues. Part II, Mysteries, presents a series of remarkable cases that perplex even the most seasoned clinicians. Lastly, Uncertainty explores the common situations in medicine in which even highly trained physicians are required to act with imperfect knowledge. Written for both practitioners and patients, Complications effectively opens up the fascinating, previously hidden world of surgery to its readers.
Perrow C. Princeton, NJ: Princeton University Press; 1999. ISBN: 0691004129.
Though less often cited than high-reliability theory in the health care literature, normal accidents theory is equally prominent in the study of complex organizations. A more pessimistic view, normal accidents theory suggests that, in some settings, a major accident becomes almost inevitable. Perrow identifies "complexity" and "tight coupling" as the two factors that create an environment in which a major accident becomes more rather than less probable over time, regardless of steps taken to increase safety. The degree of complexity Perrow has in mind occurs when no single operator can immediately foresee the consequences of a given action in the system. Tight coupling occurs when processes are intrinsically time-dependent: once a process has been set in motion, it must be completed within a certain period of time. Many health care organizations would meet Perrow's definition of complexity, but only hospitals would be regarded as exhibiting tight coupling. Nuclear power provides the archetypal complex, tightly coupled system, and an analysis of the near disaster at Three Mile Island provides the centerpiece of the book. Even if one does not share Perrow's conclusion about the potential for catastrophe as an intrinsic property of certain complex systems, the case studies offer many fascinating insights into the possible failure modes for complex organizations, including hospitals.
Doctor’s orders killed cancer patient: Dana-Farber admits drug overdose caused death of Globe columnist, damage to second woman.
Knox RA. The Boston Globe. March 23, 1995; Metro/Region section: 1.
This column chronicles the tragic death of Betsy Lehman, a Boston Globe health columnist, who fell victim to an inadvertent overdose of chemotherapy while receiving treatment for breast cancer at the Dana-Farber Cancer Institute. The story details the events surrounding the case, the reactions among family and the public, and the response from Dana-Farber.
Gerteis M, Edgman-Levitan S, Daley J, Delbanco TL, eds. San Francisco, CA: Jossey-Bass; 1993. ISBN 9781555425449.
Authored by several leaders of the Picker/Commonwealth Program for Patient-Centered Care, this book demonstrates the broad impact of the program. The authors discuss the key tenets of patient-centered care, drawing on empirical research, theory, and results of many surveys of patients, providers, and administrators. The authors provide many practical suggestions, a number of which have been adopted since the book's first publication in 1993. Examples include giving patients access to their medical records, giving them ''written and/or visual information identifying members of the clinical team," and offering ''culturally sensitive educational materials tailored to specific ethnic groups.''
Journal Article > Review
Tennen H, Affleck G. Psychol Bull. 1990;108:209-232.
This detailed review summarizes existing evidence on how people adapt to threatening events by blaming others. Discussion includes a synthesis of past work and explanations for findings from both the psychoanalytic perspective and the social psychology literature. Based on their assessment that these explanations fall short, the authors present a different model that focuses on factors influencing the incidence of blaming others and the consequences of doing so. Their model argues for a relationship between situational factors and personal characteristics, with interpersonal and intrapersonal mediators playing a role, which ultimately leads to adaptation and blame of others. They include a discussion of limitations in their proposed model as well as recommendations for future study.
Journal Article > Study
Heyland DK, Barwich D, Pichora D, et al; ACCEPT (Advance Care Planning Evaluation in Elderly Patients) Study Team; Canadian Researchers at the End of Life Network (CARENET). JAMA Intern Med. 2013;173:778-787.
Advance care planning (ACP) has become an increasingly utilized process for exploring and communicating patients' preferences for end-of-life care. This multicenter audit of ACP practices across 12 hospitals in Canada found that even when patients and families have completed ACP, inpatient health care providers are not discussing these preferences during hospitalization nor are they documenting these decisions in the medical record. When there was chart documentation, it did not match the patients' expressed wishes more than two-thirds of the time. The majority of audited cases found that patients were prescribed more aggressive care than they would have preferred. An accompanying editorial argues that these types of "silent misdiagnoses" should be considered medical errors, noting that discussions about code status and ACP are "every bit as important to patient safety as a central line placement or a surgical procedure." A previous AHRQ WebM&M commentary discussed ACP and other tools for expressing end-of-life preferences.
Journal Article > Study
Patient safety, satisfaction, and quality of hospital care: cross sectional surveys of nurses and patients in 12 countries in Europe and the United States.
Aiken LH, Sermeus W, Van den Heede K, et al. BMJ. 2012;344:e1717.
Seminal studies in the United States have shown strong associations between nurses' working conditions and patient safety, with high patient-to-nurse ratios and greater patient turnover being linked to increased mortality. This multinational survey of nurses and patients found that improved nurse work environments and reduced patient-to-nurse ratios were linked to better perceptions of quality and patient satisfaction. Moderately strong correlations were found between patient satisfaction and nursing reports of care quality, although there were wide variations in both measures across different countries. This study lends additional support to the view that improving the work environment for nurses can strengthen patient safety.
Gawande A. New York, NY: Metropolitan Books; 2009. ISBN: 9780805091748.
Harvard surgeon Atul Gawande has emerged as this generation's preeminent physician–author, through his articles in The New Yorker on topics ranging from quality improvement to the costs of health care, and his books, Complications and Better. In his new book, The Checklist Manifesto: How to Get Things Right, Dr. Gawande elegantly describes the history of the checklist as a quality and safety tool, in fields ranging from flying airplanes to building skyscrapers. In health care, he focuses on the Michigan Keystone Project, in which the use of checklists led to a remarkable decrease in the rate of central line–associated bloodstream infections, and on his own work with the World Health Organization's Safe Surgery Saves Lives program, where checklist use was associated with a striking decrease in surgical complications. An AHRQ WebM&M interview with Dr. Gawande discusses professionalism, surgical errors, and patient safety. A Patient Safety Primer on checklists is also featured on AHRQ PSNet.
King S. New York, NY: Atlantic Monthly Press; 2009. ISBN: 9780802119209.
This memoir shares the story of Sorrel King's crusade to make medical care safer. Sorrel King is the mother of Josie King, who died tragically in 2001 at age 18 months because of medical errors during a hospitalization at Johns Hopkins Hospital. She has subsequently become one of the nation's foremost patient advocates for safety, forming an influential foundation (the Josie King Foundation) and partnering with Johns Hopkins to promote the field of patient safety around the world.
Gawande A. The New Yorker. December 10, 2007;83:86-95.
This article by bestselling author and surgeon Atul Gawande illustrates the complexity of intensive care and profiles Peter Pronovost, the Johns Hopkins intensivist and safety leader whose efforts to standardize safety practices led to remarkable reductions in ICU harm in Michigan hospitals. It goes on to a broader discussion of how checklists and decision support have reduced errors and transformed safety in critical care. Gawande also reflects on how implementation of standardized approaches often conflicts with the traditional physician culture, which prizes individual expertise over all else.
Journal Article > Commentary
Delbanco T, Bell SK. N Engl J Med. 2007;357:1682-1683.
Disclosure of medical errors remains an important and challenging practice, with a past report providing thoughtful guidance on how to respond. This commentary addresses the humanistic aspect of what patients, families, and clinicians go through in trying to bring closure or forgiveness to the experience. Drawing from interviews highlighted in a documentary film, the authors share a number of specific themes not frequently addressed. These include feelings of concern by patients about the potential for further harm to occur, feelings of isolation by patients from their clinicians when they need them the most, and feelings of guilt by family members that often exceed those of providers. An AHRQ WebM&M commentary, perspective, and interview also discuss multiple facets of error disclosure.
Groopman J. Boston, MA: Houghton Mifflin; 2007. ISBN: 0618610030.
In this book, the author presents several stories that illustrate the forces that shape physician decision-making and may lead to diagnostic mistakes. Borrowing from the field of cognitive psychology, a number of errors stemming from clinicians' use of heuristics, or ''rule of thumb'' shortcuts, are highlighted. This book introduced these concepts on a popular level to many clinicians and the public. The book also discusses the role patients can play to minimize these mistakes. A prior AHRQ WebM&M perspective discussed diagnostic errors and provided advice for reducing cognitive slips.
Journal Article > Study
Coleman EA, Parry C, Chalmers S, Min SJ. Arch Intern Med. 2006;166:1822-1828.
Prior studies have documented the safety problems that befall patients with complex illnesses at the time of transition from one setting of care to another. In this trial conducted in an integrated delivery system, patients were randomized to receive usual care or the care transitions intervention at the time of hospital discharge. Intervention patients received a personal health record and a "transition coach," who assisted with continuity of care across settings, arranged home visits after discharge, and helped train patients and caregivers in self-care methods. The foci of the intervention were on ensuring accurate medication usage and appropriate follow-up care. The intervention successfully reduced the likelihood of hospital readmission for 3 months after discharge and appeared to be cost effective.