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- WebM&M Cases 1
- Perspectives on Safety 6
- Review 4
- Study 7
- Audiovisual 21
- Book/Report 5
- Legislation/Regulation 1
- Newspaper/Magazine Article 101
- Newsletter/Journal 1
- Special or Theme Issue 2
- Web Resource 5
- Award 1
- Press Release/Announcement 1
- Communication Improvement 6
- Culture of Safety 8
Education and Training
- Students 1
- Error Reporting and Analysis 29
- Human Factors Engineering 5
Legal and Policy Approaches
- Role of the Media
- Logistical Approaches 4
- Quality Improvement Strategies 15
- Teamwork 1
- Technologic Approaches 10
- Transparency and Accountability 2
- Device-related Complications 2
- Diagnostic Errors 21
- Discontinuities, Gaps, and Hand-Off Problems 10
- Drug shortages 4
- Fatigue and Sleep Deprivation 4
- Identification Errors 2
- Medical Complications 18
- Medication Errors/Preventable Adverse Drug Events 13
- Overtreatment 1
- Psychological and Social Complications 8
- Surgical Complications 20
- Internal Medicine 52
- Nursing 5
- Pharmacy 6
- Family Members and Caregivers 4
- Health Care Executives and Administrators 39
Health Care Providers
- Nurses 2
Non-Health Care Professionals
- Media 5
- Patients 120
Search results for "Role of the Media"
- Role of the Media
Web Resource > Multi-use Website
ProPublica, Inc. New York, NY.
Rau J. National Public Radio. July 27, 2016.
Although quality rating systems have yet to receive approval across the health care industry, they still serve as a way for consumers to select hospitals and providers. The developers of rating services continue to refine metrics to hone their effectiveness. This news article reports on the latest set of ratings from the Hospital Compare program and concerns associated with the results.
Frakt A. New York Times. July 11, 2016.
Patients are increasingly using online symptom checkers for medical information and health care recommendations. This newspaper article reports on various health information applications that provide triage advice to patients and points out that physicians have significantly lower rates of diagnostic errors.
Aleccia J. Seattle Times. June 18, 2016.
Patients who experience harm while receiving medical care can serve as powerful advocates for patient safety. This news article reports on a patient who became engaged in working to redesign processes to improve patient safety after he became paralyzed from the chest down due to a cascade of communication errors.
Journal Article > Study
Perceptions of medical errors in cancer care: an analysis of how the news media describe sentinel events.
Li JW, Morway L, Velasquez A, Weingart SN, Stuver SO. J Patient Saf. 2015;11:42–51.
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.
Journal Article > Study
High-profile investigations into hospital safety problems in England did not prompt patients to switch providers.
Laverty AA, Smith PC, Pape UJ, Mears A, Wachter RM, Millett C. Health Aff (Millwood). 2012;31:593-601.
While medical errors continue to affect patients on a daily basis, most organizations fear high-profile cases that land on front pages of newspapers or lead to extensive regulatory intervention. This study evaluated the role of England's Care Quality Commission in their own regulatory investigation of major issues occurring in three hospitals. The investigations led to considerable media attention, but whether this influenced patient behavior was unknown. The authors found that the investigations had zero impact on utilization at two of the hospitals. The third experienced a decrease in inpatient admissions and new patient visits, but the effect dissipated 6 months following the public report. In an era of greater transparency and increased attention on patient safety, these findings suggest that patients' decision-making is perhaps less influenced than expected by such events. Two past AHRQ WebM&M perspectives discussed organizational change in the face of highly public errors at Duke and the Dana Farber Cancer Institute.
Snyderman N. NBC News. February 22, 2012.
This news video reports how inadequate sterilization of surgical instruments can affect patient safety.
Vaida B. The Washingtonian. January 27, 2012.
This magazine article discusses patient safety improvement efforts as well as challenges hindering more widespread error reduction.
Journal Article > Study
Hinchcliff R, Westbrook J, Greenfield D, Baysari M, Moldovan M, Braithwaite J. Int J Qual Health Care. 2012;24:1-8.
Communication Advisory Committee. Edmonton, AB, Canada: Canadian Patient Safety Institute; 2010. ISBN: 9781926541266
This guideline provides an organizational strategy, flow charts, and a task list to improve internal and external communication following a medical error.
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.
Perspectives on Safety > Perspective
with commentary by Robert M. Wachter, MD, The Role of the Media in Patient Safety, October 2009
December 1 marks the tenth anniversary of the Institute of Medicine (IOM) report To Err Is Human, the blockbuster that launched the modern patient safety movement.(1) The anniversary provides an opportunity to reflect on the forces that have promoted safety efforts over the past decade. They include a more robust accreditation environment, increased reporting of adverse events to state and other regulatory bodies, growing implementation of information technology, skill-building support by organizations such as Institute for Healthcare Improvement, and a maturing research field supported by AHRQ and others.
Journal Article > Study
Stebbing C, Kaushal R, Bates DW. Pediatrics. 2006;117:1907-1914.
This study analyzed newspaper coverage of pediatric medication errors and adverse drug events in five countries to demonstrate increased interest in the topic over the past decade. Investigators examined the number of articles and the types of events covered and assessed the overall themes presented and framed by the media. The majority of articles published covered patient incidents followed by policy and then research in decreasing order of frequency. Despite the occasional occurrence of sensational reporting on errors, more than 70% of articles that were deemed to be negatively associated with patient safety were covered in a neutral manner.
Journal Article > Review
Millenson ML. Qual Saf Health Care. 2002;11:57-63.
This article highlights the role of the news media in catalyzing the patient safety movement. The author maintains that the medical profession adopted an “ostrich-like attitude” toward medical errors prior to the intensified media coverage of high-profile mistakes. In the postwar era, trust in physicians was high, and the media profiled mainly scientific progress. In the past two decades, media coverage of medical mishaps has increased and changed the attitude toward patient safety. The author cites specific cases profiled in the media and the changes these cases prompted in the medical system, including a number of large-scale patient safety committees, projects, and landmark legislation.
Hixenbaugh M, Ornstein C. Houston Chronicle and Propublica.
This news investigation chronicles a series of incidents in a transplant program that resulted in patient harm. The systemic nature of the problems such as insufficient whistleblower protection, accountability, and follow-up on patient concerns culminated in a change of hospital leadership. A previous PSNet interview with Charles Ornstein discussed the role of media in raising awareness of patient safety issues.
Kowalczyk L. Boston Globe. August 14, 2016.
Certain elements of the ambulatory surgery environment can increase risk of adverse events. Reporting on a series of patient injuries linked to a contracted anesthesiologist at a cataract surgery center, this news article describes how factors such as production pressure and insufficient assessment of contract anesthesiologists' qualifications can contribute to adverse events in outpatient surgery.
Ghaferi AA, Myers C, Sutcliffe KM, Pronovost PJ. Harv Bus Rev. July/August 2016;94.
Achieving high reliability is a recognized goal for health care organizations. Reviewing current technical and standardization enhancements to augment quality and safety in surgery, this article explores how implementing high reliability concepts could further improve safety in surgical care over time.
Miller N. The Pathologist. June 2016(20):18-29; July 2016(21):18-33.
In light of the growing focus on diagnostic errors, this magazine series reports on unique challenges that pathologists face when they discover potential errors. The first article in the series discusses how pathologists may experience barriers to disclosure including feeling shame in disclosing their own error, discomfort with raising concerns about a colleague who has misdiagnosed a patient, and lack of direct relationships with patients. The second article expands the discussion to focus on how industry support of open transparency can enable pathologists to participate in reporting and disclosure activities.
Robbins A. Good Housekeeping. May 20, 2016.
Disruptive behaviors are receiving increased attention as a cultural factor that contributes to medical error. Although much of the focus has been on physicians, the presence of bullying among nurses is also a concern. This magazine article explores nurse behaviors such as withholding information, intimidation, and name calling that negatively affect patient safety and nurse retention.
Rau J. Washington Post. May 17, 2016.
Collecting data to meet quality measurement requirements adds to resource burden for many health care organizations, and there is controversy around the benefits of such rating systems for both patients and clinicians. This news article discusses problems with the Centers for Medicare and Medicaid Services rating mechanism, Hospital Compare.
Landro L. Wall Street Journal. May 9, 2016.
Closed claims have been considered a source for adverse event data for years, and recently such data has been utilized to inform safety improvement work. This newspaper article reviews several organizational efforts that use claims data to determine factors that contribute to failure and strategies to address them, including process redesign and enhanced patient education.
Rau J. Washington Post. April 29, 2016.
Transitions in care between inpatient and outpatient settings are an increasing concern for patient safety. Reporting on a fatal medication error that was missed by a patient's pharmacist and home health nurses, this newspaper article discusses various risks associated with hospital-to-home transitions such as insufficient case management and communication.
Journal Article > Study
Lagu T, Goff SL, Craft B, et al. J Hosp Med. 2016;11:52-55.
Researchers in this study reviewed patient feedback posted on a hospital's Facebook page to determine whether social media may be a helpful mechanism for identifying patient safety and quality improvement issues. In this small sample of 37 respondents over a 3-week period, insights from social media comments did not seem to add much to the feedback already collected by more traditional methods, such as patient satisfaction surveys.
Journal Article > Review
Systematic review on the prevalence, frequency and comparative value of adverse events data in social media.
Golder S, Norman G, Loke YK. Br J Clin Pharmacol. 2015;80:878-888.
Medication errors are common in the outpatient setting and frequently lead to emergency department visits and hospital admissions. The growth in social media use potentially provides a way to identify safety hazards quickly. This systematic review sought to examine whether social media could provide unique insights into safety issues compared to standard methods of detecting safety hazards. The included studies searched a variety of social media sites (e.g., Twitter, YouTube, and discussion forums) and found that a large number of adverse events are discussed in real time. Most of these events tended to be mild, such as symptoms or asymptomatic lab test abnormalities. Serious adverse events, those requiring urgent treatment or hospitalization, were relatively underrepresented. Although searching social media may help identify unique safety hazards, the investigators concluded that current evidence is insufficient to determine whether routine analysis of social media is of added benefit to traditional surveillance methods.
Inside Canada's secret world of medical error: 'There is a lot of lying, there's a lot of cover-up.'
Blackwell T. National Post. January 16, 2015.
Koba M. Fortune. January 6, 2015.
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.
Dunklin R, Thompson S. Dallas Morning News. December 6, 2014.
This news article reports on the widely publicized delayed diagnosis of Ebola at a Dallas hospital and reveals previously undisclosed details from the emergency room physician who misdiagnosed the patient when he first presented, including information and communication gaps that may have contributed to the failure.
Journal Article > Review
Wu AW, Kavanagh KT, Pronovost PJ, Bates DW. J Patient Saf. 2014;10:181-185.
In light of an unreported conflict of interest that might have affected recommendations for chlorhexidine use to reduce risk of central line–associated infections, this review examines articles written or coauthored by Dr. Charles Denham to determine whether undeclared conflicts of interest could have influenced conclusions, selections, and recommendations in published research. The authors emphasize the need to identify and address conflicts of interest and outline strategies to reduce risk of undisclosed conflicts which may in turn affect validity of published evidence.
Stock S, Putnam J, Carroll J, Pham S. NBC Bay Area. November 19, 2014.
Hospital reporting of errors in the United States has been suboptimal. This news video investigates the effectiveness of a state reporting initiative in California. Although hospitals have reported 6282 adverse events to the state in 4 years, patient safety experts suggest that those results do not reliably represent all the incidents that should have been submitted.
Carville O. The Star. November 14, 2014.
This news article reports on a case involving a patient who was misdiagnosed with terminal cancer and touches on the psychological impact of diagnostic error on the patient and his family. The potential causes of the mistake include laboratory sample confusion and misinterpretation of biopsy results.
Goldman B. "White Coat, Black Art." CBC Radio. October 31, 2014.
This radio segment explores whether sleep deprivation affects the safety of care delivery. Panelists discuss sleep deprivation in health care, the influence of hierarchy and peer behaviors in normalizing fatigue, and the impacts of duty hour limits on patient safety. This contributes to the continuing debate about the benefits of work hour reductions and its potential to detract from residents' competency.
Gubar S. New York Times. October 30, 2014.
This newspaper article describes how surgical complications, health care–associated infections, and ineffective patient–provider communication contributed to a patient's experience with harm and suggests that transparency around the incident and preoperative patient briefings could have improved the situation.
Webster H. US News & World Report. October 27, 2014.
This magazine article explores whether receiving care at a teaching hospital affects patient safety and highlights how the demands of the educational process can actually augment safety, as attendings at these institutions typically remain up-to-date on new evidence to respond to students' questions and supervision is required for students performing procedures.
Ryan J. All Things Considered. National Public Radio. October 16, 2013.
This radio news segment reports on patient falls, including risk factors and prevention strategies.
Rodricks D. Baltimore Sun. October 14, 2014.
Although significant progress has been made in improving patient safety over the past decade, many medical errors continue to occur. In light of the recent incident involving transmission of the Ebola virus from a patient to a nurse at a Dallas hospital, this newspaper article reports on how lapses in following standard procedures in care environments, such as insufficient handwashing, can result in preventable harm.
Loftis RL. Dallas Morning News. October 5, 2014.
Guidelines and rules are developed to help augment safety, but they cannot guarantee it. This news article explores the potential causes for a missed diagnosis of Ebola despite screening procedures for the virus, including weaknesses in an electronic health record system, complacency, and poor communication.
Beck M. Wall Street Journal. September 14, 2014.
Overdiagnosis has emerged as a patient safety issue. Reporting on how the push for early identification of cancer has led to screening, detection, and treatment of tumors that may never cause harm, this newspaper article discusses the impact of unnecessary tests and treatment on patients and health systems. Researchers are working to design better tests to distinguish between benign abnormalities and cancers.
Hartocollis A, Goodman JD. New York Times. September 9, 2014.
Office-based anesthesia is becoming more common despite concerns regarding its safety. This newspaper article reports on factors to enhance safety of surgical care in ambulatory settings, such as adequate screening of patient risks, availability of staff trained to perform intubations when needed, and ensuring access to lifesaving equipment as strategies.
O'Donnell J. USA Today. September 7, 2014.
Kowalczyk L. Boston Globe. August 31, 2014.
Reporting on an incident involving administration of an inappropriate dye which led to a patient's death, this newspaper article reveals how cognitive biases may have played a role and steps the hospital took to prevent similar errors. Six Massachusetts hospitals have launched a pilot program for early apology and resolution in an effort to enhance patient satisfaction and safety.
Sathya C. CNN. August 22, 2014
This news article reports on the development a surgical black box, which includes using cameras and microphones to record procedures, as a way to track weaknesses in techniques and processes while providing real-time feedback to surgeons and enabling timely intervention to reduce complications in surgery.
Pierrotti A. USA Today. August 18, 2014.
Parikh R. The Atlantic. August 18, 2014.
The inappropriate use of physical restraints on patients is considered a sentinel event. Although restraints may be used to protect patients from harm, this magazine article highlights risks related to their use—such as increased rates of pressure ulcers and delirium—and advocates for a more patient-sensitive approach to ensure the safety of both patients and caregivers.
Flatten M. Washington Examiner. August 18–22, 2014.
Hobson K. US News World Report. August 13, 2014.
This magazine article highlights advances in patient safety efforts along with documented challenges to progress. Surgical checklists, forcing functions in electronic health records, and daily huddles for leaders to talk about concerns are discussed as strategies implemented to reduce adverse events in hospitals.
Carr S. Patient Saf Qual Healthc. July/August 2014;11:30-35.
This magazine article summarizes experts' projections for the patient safety movement in the next 5 years. Areas discussed include expanding the focus of safety to investigate public health concerns, enhancing patient engagement, improving interoperability of electronic health records, and driving culture change.
Clark C. HealthLeaders Media. August 7, 2014.
Although California has collected an estimated $15 million in penalties from hospitals for adverse events, this news piece describes how much of the money has yet to be allocated or spent on safety improvement projects. Moreover, some state agencies have been reluctant to provide specific data to projects that have already been funded.
O'Donnell J. USA Today. August 6, 2014.
This newspaper article reports on changes to publicly reported data on the Hospital Compare Web site. Several avoidable hospital-acquired conditions, such as air embolism or retained foreign objects, are no longer included. Working with the National Quality Forum, the Centers for Medicare and Medicaid Services (CMS) decided to modify the list to make it easier for consumers to use and understand.