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- WebM&M Cases 3
- Perspectives on Safety 2
- Review 1
- Study 3
- Slideset 1
- Book/Report 9
- Newspaper/Magazine Article 61
- Special or Theme Issue 1
- Toolkit 2
- Web Resource 13
- Meeting/Conference 1
- Press Release/Announcement 1
- Communication Improvement 21
- Culture of Safety 8
- Education and Training 18
Error Reporting and Analysis
- Error Reporting 19
- Human Factors Engineering 17
- Legal and Policy Approaches 18
- Logistical Approaches 4
- Policies and Operations 1
- Quality Improvement Strategies 24
- Research Directions 1
- Specialization of Care 5
- Clinical Information Systems 8
- Device-related Complications 10
- Diagnostic Errors 4
- Discontinuities, Gaps, and Hand-Off Problems 11
- Drug shortages 3
- Fatigue and Sleep Deprivation 1
- Identification Errors 9
- Interruptions and distractions 1
- Medical Complications 17
- Medication Errors/Preventable Adverse Drug Events 57
- Nonsurgical Procedural Complications 5
- Psychological and Social Complications 1
- Surgical Complications 12
- Internal Medicine 22
- Pediatrics 20
- Nursing 9
- Pharmacy 24
- Family Members and Caregivers 5
- Health Care Executives and Administrators 39
Health Care Providers
- Nurses 6
Non-Health Care Professionals
- Media 4
- Australia and New Zealand 1
- Europe 6
- Canada 2
Search results for "Hospitals"
Appleby J, Lucas E. Kaiser Health News. August 14, 2019.
Appleby J, Lucas E. Kaiser Health News. June 21, 2019.
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.
Kowalczyk L. Boston Globe. May 27, 2018.
Pediatric patients are particularly vulnerable to medication errors. This news article reports on serious medication errors that occurred at Children's Hospital in 2017, the underlying system failures that contributed to the incidents, and challenges to implementing new policies meant to prevent similar errors.
Journal Article > Review
Consumer mobile apps for potential drug–drug interaction check: systematic review and content analysis using the Mobile App Rating Scale (MARS).
Kim BY, Sharafoddini A, Tran N, Wen EY, Lee J. JMIR Mhealth Uhealth. 2018;6:e74.
Patients are powerful allies in improving medication safety. This study found that available mobile applications that enable patients to check for drug–drug interactions are of moderate quality and low cost. They did not assess efficacy. An Annual Perspective examined other technological innovations for engaging patients in safety.
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.
Tools/Toolkit > Government Resource
Centers for Disease Control and Prevention.
The opioid crisis is a persisting patient safety problem. One approach to prevent misuse of opioids is to raise awareness of the addictive nature of the medication. This national campaign enlists communities and individual clinicians to provide patient education to address the opioid epidemic. The website offers videos and other resources to assist community-level efforts to reduce risk for opioid addiction.
National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies Press: 2017. ISBN: 9780309461856.
Patient health literacy is a known challenge in health care safety. This publication reports on results of a multidisciplinary workshop that explored health literacy improvement strategies and tools to enhance the clarity of labels, patient instructions, and decision aids to support safe medication use.
Furfaro H. Wall Street Journal. September 25, 2016.
Medication errors in pediatric care are common in the hospital and at home. This newspaper article reports on problems associated with medication safety among pediatric patients and highlights several tools both clinicians and parents can use to enhance safety when administering medicine to children, including dosage calculators and pictures depicting medication administration processes.
Gorman A. Kaiser Health News. August 30, 2016.
Older patients are particularly vulnerable to medication errors, as they are often prescribed multiple medications for chronic conditions. This news article reports on complexities associated with managing medications in older patients, including how miscommunication between care team members and patient misunderstanding of postdischarge medication changes can increase risks and contribute to preventable harm. A recent WebM&M commentary discussed strategies to safely manage medications in older patients and highlighted the importance of medication reconciliation.
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.
Web Resource > Government Resource
Centers for Disease Control and Prevention.
Roe S, King K. Chicago Tribune. February 10–13, 2016.
Drug interactions can be hazardous to patients, particularly when combined with risk factors such as age and use of medications for chronic conditions. This series of news reports discusses the problem of drug interactions, including one patient's experience of severe harm and researchers' use of data mining to identify medication pairs linked to high-risk interactions. The series also includes a list of steps patients can take to reduce risk of harmful interactions between medicines they take.
Selected medication safety risks to manage in 2016 that might otherwise fall off the radar screen—part 1 and part 2.
ISMP Medication Safety Alert! Acute Care Edition. January 28, 2016;21:1-4. February 11, 2016;21:1-5.
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.
Tavernise S. New York Times. January 15, 2015.
This newspaper article discusses an investigation into how a saline solution that had been manufactured specifically for training purposes was inadvertently distributed and used for actual care and led to patient harm and death.
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.
Eisler P, Hansen B. USA Today. August 20, 2013.
This newspaper article reports on physicians with records of misconduct and how poor oversight for monitoring and discipline allows them to continue practicing medicine.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; December 6, 2012.
Kane J. PBS NewsHour. October 23, 2012.
This video reveals how checklists can help patients and their families ensure safety during hospital care.