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- Communication Improvement 10
- Education and Training 2
- Error Reporting and Analysis 5
- Human Factors Engineering 1
- Legal and Policy Approaches 8
- Logistical Approaches 2
- Policies and Operations 2
- Quality Improvement Strategies 9
- Specialization of Care 2
- Technologic Approaches 5
- Transparency and Accountability 1
- Diagnostic Errors 11
- Discontinuities, Gaps, and Hand-Off Problems 8
- Failure to rescue 2
- Fatigue and Sleep Deprivation 1
- Medication Errors/Preventable Adverse Drug Events 5
- Nonsurgical Procedural Complications 1
- Psychological and Social Complications 3
- Transfusion Complications 1
- Internal Medicine 8
- Nursing 1
- Pharmacy 2
- Family Members and Caregivers 3
- Health Care Executives and Administrators 12
Health Care Providers
- Nurses 2
- Non-Health Care Professionals 5
Search results for "Hospitals"
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.
DeMarco P. Globe Magazine. November 3, 2018.
This magazine article reports on the preventable death of a patient during an acute asthma attack. Written by the patient's husband, the article outlines the failures that led to her death despite the fact that she was at the door of a hospital emergency department and on the phone with an emergency dispatcher. Factors discussed include overreliance on poorly functioning technology, communication failures, and lack of fail-safes.
Daley J. Colorado Public Radio. February 23, 2018.
Innovations in the prescribing of opioids in the emergency department are needed to change practice and help address the opioid crisis. This news article reports the results of a 10-hospital pilot program, the Colorado Opioid Safety Collaborative, which used alternative pain control approaches to reduce opioid prescriptions by an average of 36%. The program builds on multidisciplinary teamwork to modify pain management in the emergency department. An Annual Perspective highlighted opioid misuse as a patient safety challenge.
Hoffman J. New York Times. June 10, 2016.
Overprescribing of opioids for pain management contributes to the growing crisis involving opioid-related harm. This newspaper article reports on one hospital's efforts to avoid opioid use for patients presenting to the emergency department with pain. Alternative treatments included nonnarcotic infusions, nitrous oxide, music therapy, and holistic techniques.
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.
Journal Article > Study
The Ask Me to Explain campaign: a 90-day intervention to promote patient and family involvement in care in a pediatric emergency department.
Tothy AS, Limper HM, Driscoll J, Bittick N, Howell MD. Jt Comm J Qual Patient Saf. 2016;42:281-286.
This study reports on efforts to enhance communication between clinicians and patients in an urban pediatric emergency department. A rapid-change project resulted in significant improvement in patient perceptions of communication—clinicians were perceived as being more sensitive to patients' concerns and displayed better listening behaviors. Poor discharge communication in the emergency department has been linked to safety concerns in prior studies.
Donnelly L. The Telegraph. January 31, 2016.
Delays in care and diagnosis can result in patient harm. This news article reports on the trend of delays in prehospital emergency care as a safety concern in the United Kingdom and describes an incident involving an infant who died from sepsis after a call handler from the NHS 111 service failed to recognize that the child required urgent care.
Shell ER. Sci Am. 2015;313(5):28-29.
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.
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.
Silverman L. Morning Edition. National Public Radio. June 9, 2014.
This radio segment discusses the experience of a pediatric medical center that hired pharmacists for its emergency department to review medication orders before the medicine is dispensed and administered in an effort to prevent medication errors.
Burcham K. WSOC-TV. November 22, 2013.
This news piece reports on a missed diagnosis of meningitis and illustrates how premature closure can hinder safe care.
Dwyer J. New York Times. October 25, 2012.
Dwyer J. New York Times. July 11, 2012:A15.
This newspaper article reports on gaps in communication and a missed sepsis diagnosis that led to a patient's death.
Gupta S. New York, NY: Grand Central Publishing; 2012. ISBN: 9780446583855.
To illustrate how physicians learn from mistakes, this novel (written by CNN medical correspondent Dr. Sanjay Gupta) explores the impact of a medical error on surgeons at one hospital.
Eban K. Self Magazine. November 2011.
This magazine article reports on cases in which outsourcing the interpretation of radiology tests contributed to patient harm.
Landro L. Wall Street Journal. May 10, 2011:D3.
This newspaper article reports on efforts to reduce errors in emergency medicine, including improving physician–nurse communication, adopting timeouts before discharge, and using trigger systems.
Lucado J, Paez K, Elixhauser A. HCUP Statistical Brief #109. Rockville, MD: Agency for Healthcare Research and Quality; April 2011.
Tools/Toolkit > Fact Sheet/FAQs
Clancy CM. Rockville, MD: Agency for Healthcare Research and Quality; September 1, 2009.
This column offers advice for consumers on what personal health and medical information to prepare before going to the emergency department.
Web Resource > Multi-use Website
Dallas, TX: American College of Emergency Physicians.
This Web site provides access to emergency medical services evaluations in four categories: access, quality and patient safety, public health and prevention, and medical liability environment. The site also offers an interactive map of the nation, with detailed information and a "grade" for each state.