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- Patient Safety Primers 1
- WebM&M Cases 8
- Perspectives on Safety 5
- Commentary 23
- Review 3
- Study 51
- Slideset 1
- Book/Report 59
- Legislation/Regulation 4
- Newspaper/Magazine Article 417
- Newsletter/Journal 1
- Special or Theme Issue 9
- Toolkit 8
- Web Resource 94
- Award 3
- Grant 1
- Meeting/Conference 3
- Press Release/Announcement 21
- Communication between Providers 51
- Culture of Safety 37
Education and Training
- Students 3
Error Reporting and Analysis
- Error Reporting 130
Human Factors Engineering
- Checklists 24
Legal and Policy Approaches
- Regulation 24
- Logistical Approaches 29
- Policies and Operations 4
Quality Improvement Strategies
- Benchmarking 13
- Research Directions 5
- Specialization of Care 21
- Teamwork 18
- Clinical Information Systems 46
- Transparency and Accountability 15
- Alert fatigue 3
- Device-related Complications 40
- Diagnostic Errors 92
- Discontinuities, Gaps, and Hand-Off Problems 55
- Drug shortages 6
- Failure to rescue 4
- Fatigue and Sleep Deprivation 11
- Identification Errors 34
- Interruptions and distractions 2
- Delirium 1
- Medication Errors/Preventable Adverse Drug Events 87
- MRI safety 1
- Nonsurgical Procedural Complications 17
- Overtreatment 7
- Psychological and Social Complications 44
- Surgical Complications 134
- Transfusion Complications 4
- Home Care 13
- General Hospitals 169
- Long-Term Care 10
- Outpatient Surgery 15
- Patient Transport 1
- Psychiatric Facilities 5
- Allied Health Services 2
- Geriatrics 20
- Obstetrics 20
- Pediatrics 68
- Primary Care 19
- Radiology 17
- Internal Medicine 241
- Nursing 19
- Palliative Care 2
- Pharmacy 43
- Family Members and Caregivers 57
- Health Care Executives and Administrators 196
Health Care Providers
- Nurses 20
- Physicians 85
Non-Health Care Professionals
- Educators 21
- Media 10
- Australia and New Zealand 6
- Europe 45
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United States of America
United States Federal Government
- Department of Health and Human Services (HHS) 56
- United States Federal Government 61
Search results for "Medicine"
Rein L. Washington Post. August 30, 2019.
Frakt A. New York Times. August 26, 2019.
The slow adoption of improvement innovations is a persistent challenge to high-quality and safe patient care. This newspaper article raises concerns about how common treatments are recommended despite insufficient evidence regarding their effectiveness and provides examples of how this problem can result in harm, such as the previous physician belief that opioids were not addictive. Reassessment of science can improve safety and reduce the unintended consequences of ineffective treatments.
Armstrong D. ProPublica. August 23, 2019.
Appleby J, Lucas E. Kaiser Health News. August 14, 2019.
Panner M. Forbes. August 12, 2019.
Diagnostic errors can result in harm across the spectrum of practice. Discussing cognitive and system factors in radiology that contribute to diagnostic mistakes, this magazine article recommends ways to reduce risk of errors, including peer review of practice, structured reporting, and artificial intelligence–enabled decision support.
Web Resource > Multi-use Website
8230 Old Courthouse Road, Suite 420, Tysons Corner, VA.
A comprehensive systems-focused approach must be employed in the hospital and at home to ensure reliable medication use. This institute supports multistakeholder activities to enhance policy and education throughout health care to optimize and improve medication practices of caregivers, families, pharmacists, and clinicians.
Whitaker P. New Statesman. August 2, 2019;148:38-43.
Artificial intelligence (AI) and advanced computing technologies can enhance clinical decision-making. Exploring the strengths and weaknesses of artificial intelligence, this news article cautions against the wide deployment of AI until robust evaluation and implementation strategies are in place to enhance system reliability. A recent PSNet perspective discussed emerging safety issues in the use of artificial intelligence.
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.
Geneva, Switzerland: World Health Organization; 2019.
Reducing adverse medication events is a worldwide challenge. This collection of technical reports explores key areas of concern that require action at a system level to improve: high-alert medications, polypharmacy, and medication use at care transitions. Each monograph provides an overview of the topic as well as practical improvement approaches for patients, clinicians, and organizations.
Web Resource > Multi-use Website
American Hospital Association.
Maternal harm is a patient safety concern that is increasingly prioritized in regulatory and care delivery environments. This website provides tools, policies, news articles, case studies, and information for patients and families to inform efforts to protect mothers and infants across geographic regions.
Journal Article > Study
DesRoches CM, Bell SK, Dong Z, et al. Ann Intern Med. 2019;171:69-71.
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.
Lives Lost, Lives Saved: An Updated Comparative Analysis of Avoidable Deaths at Hospitals Graded by The Leapfrog Group.
Austin M, Derk J. Baltimore, MD: Armstrong Institute for Patient Safety and Quality, and Johns Hopkins Medicine; May 2019.
Measures help track gaps in process and evidence of safety improvements. This white paper examines the performance of hospitals receiving Hospital Safety Grades and the relationship between high-level recognition and preventable harm. The report estimates that a substantial number of lives could have been saved if performance metrics had been met, but concludes that even high-performing hospitals exhibit areas in need of improvement.
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.
Legislation/Regulation > Colorado Legislation
Pettersen B, Tate J, Tipper K, McKean H. Colorado Senate Bill 19-201.
Communication-and-resolution mechanisms are seen as important approaches to improving transparency and healing after an adverse event. This state bill, referred to as the "Colorado Candor Act," protects conversations between organizations, clinicians, patient, and families from legal discoverability and outlines criteria to guarantee that protection.
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.
Journal Article > Study
Shen C, Nguyen M, Gregor A, Isaza G, Beattie A. JAMA Ophthalmol. 2019;137:690-692.
This study entered 42 validated clinical vignettes for eye diseases into an online symptom checker. As with prior studies, the performance of the online symptom checker in producing the correct diagnosis was suboptimal. The authors suggest that current performance of symptom checkers is not sufficient for timely and accurate diagnosis of ophthalmologic conditions.
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.