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- WebM&M Cases 3
- Perspectives on Safety 1
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- Slideset 1
- Book/Report 5
- Newspaper/Magazine Article 40
- Web Resource 5
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- Communication Improvement 12
- Culture of Safety 2
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- Error Reporting and Analysis 17
- Human Factors Engineering 10
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- Specialization of Care 2
- Clinical Information Systems 6
- Device-related Complications 4
- Discontinuities, Gaps, and Hand-Off Problems 4
- Identification Errors 5
- Interruptions and distractions 1
- Medical Complications 7
- Medication Errors/Preventable Adverse Drug Events
- Nonsurgical Procedural Complications 2
- Psychological and Social Complications 1
- Surgical Complications 5
- Internal Medicine 12
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Health Care Providers
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Non-Health Care Professionals
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Search results for "Hospitals"
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.
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.
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.
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.
Towne S. WPRI. November 2, 2011.
This article reports on a software malfunction that caused prescription errors affecting patients discharged from several Rhode Island hospitals.
Kowalczyk L. Boston Globe. September 21, 2011.
Reporting on a patient death involving alarm fatigue, this newspaper article describes how one hospital adopted aggressive measures to prevent similar incidents.
Graham J, Dizikes C. Chicago Tribune. June 27, 2011.
This newspaper article reports on an order entry error that resulted in a 60-fold overdose and raised concerns about the safety of electronic medication data systems.
Lucado J, Paez K, Elixhauser A. HCUP Statistical Brief #109. Rockville, MD: Agency for Healthcare Research and Quality; April 2011.
Valencia MJ. Boston Globe. March 10, 2011.
This newspaper article reports on a fatal medication error involving an anticoagulant overdose.
Journal Article > Commentary
Helmchen LA, Richards MR, McDonald TB. Health Care Manage Rev. 2011;36:1-10.
This commentary compares two cases of preventable medical errors and suggests disclosure and remediation as tactics to establish post–adverse event trust with families and patients.
Vedder T. Problem Solvers. KOMO 4 News. October 1, 2010.
This news piece discusses medication errors that led to adverse events in a Seattle children's hospital.