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- WebM&M Cases 2
- Perspectives on Safety 2
- Review 1
- Study 2
- Audiovisual 8
- Book/Report 4
- Newspaper/Magazine Article 37
- Toolkit 1
- Web Resource 4
- Press Release/Announcement 1
- Communication Improvement 22
- Culture of Safety 5
- Education and Training 7
- Error Reporting and Analysis 13
- Human Factors Engineering 12
- Legal and Policy Approaches 22
- Logistical Approaches 6
- Policies and Operations 1
- Quality Improvement Strategies 14
- Specialization of Care 1
- Teamwork 1
- Technologic Approaches 9
- Transparency and Accountability 1
- Alert fatigue 1
- Device-related Complications 8
- Diagnostic Errors 5
- Discontinuities, Gaps, and Hand-Off Problems 8
- Failure to rescue 1
- Fatigue and Sleep Deprivation 2
- Identification Errors 1
- Medical Complications 10
- Medication Safety 10
- Nonsurgical Procedural Complications 3
- Overtreatment 1
- Psychological and Social Complications 11
- Surgical Complications 5
- Transfusion Complications 1
- Medicine 48
- Nursing 4
- Pharmacy 5
- Family Members and Caregivers 4
- Health Care Executives and Administrators 23
Health Care Providers
- Nurses 4
- Physicians 10
Non-Health Care Professionals
- Media 2
Search results for "Hospitals"
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.
Gawande A. New Yorker. November 12, 2018.
In this magazine article, Atul Gawande describes a range of frustrations physicians experience as digitization becomes more widespread in health care. He elaborates upon several elements of electronic health record use that can degrade care processes and create conditions for errors, such as burnout, lack of patient-centeredness, and alert fatigue.
Journal Article > Study
Patient groups, clinicians and healthcare professionals agree—all test results need to be seen, understood and followed up.
Dahm MR, Georgiou A, Herkes R, et al. Diagnosis (Berl). 2018;5:215-222.
Inadequate test result follow-up places patients at risk of delayed diagnosis, especially in the ambulatory setting. Diverse stakeholders in Australia established an agenda for enhancing test result management, which included better governance, improved use of technology, and consistent patient engagement. A WebM&M commentary explored two incidents where poor test result follow-up led to patient harm.
Landro L. Wall Street Journal. August. 8, 2016.
First-year residents may be reluctant to ask for assistance due to factors such as peer pressure to demonstrate competency. This newspaper article reports on one hospital's strategy to enhance communication among residents and attendings, which encourages residents to ask questions of senior clinicians who are coached to welcome learning conversations.
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.
Olson J. Star Tribune. February 9, 2015.
Journal Article > Study
Family participation during intensive care unit rounds: goals and expectations of parents and health care providers in a tertiary pediatric intensive care unit.
Stickney CA, Ziniel SI, Brett MS, Truog RD. J Pediatr. 2014;165:1245-1251.
In this study, health care providers and parents of children in a pediatric intensive care unit described their perceptions of family involvement in morning rounds. Although parents were overwhelmingly enthusiastic about being included in rounds, providers expressed some concerns and potential drawbacks, such as the avoidance of discussing uncomfortable topics due to presence of family.
Rice S. Mod Healthc. 2014;44:16-18, 20.
Language barriers can lead to misunderstandings that increase risks of error. This magazine article highlights the frequent reliance on families, friends, and other nonprofessionals as translators in medical settings and discusses how lack of standards and insufficient reporting of errors related to interpreters, along with challenges to implementing programs, hinder progress in improving communication with non-English speaking patients.
Kimmelman M. New York Times. August 21, 2014.
This newspaper article reports on how design solutions for hospitals, such as rooms modeled for single patients with sinks placed in plain sight, handrails linking the bedside to the bathroom, and large windows with natural light and an outdoor view, can augment patient satisfaction and safety.
Chicago, IL: American Hospital Association Physician Leadership Forum; July 2014.
Lichtblau E. New York Times. June 15, 2014.
This newspaper article reports how a "culture of silence" at Veterans Affairs hospitals discouraged staff from speaking up about safety and quality concerns related to the use of inaccurate wait time data.
Catalanello R. The Times-Picayune. April 15, 2014.
Yurkiewicz I. Aeon Magazine. January 29, 2014.
Disruptive behavior is a well-known and pervasive issue in health care. Describing disrespectful behaviors that clinicians face, such as sarcasm and intimidation, this magazine article emphasizes how they can hinder effective interactions and communication to reduce patient safety.
Knox R. Morning Edition. National Public Radio. January 27, 2014.
Journal Article > Review
Promoting engagement by patients and families to reduce adverse events in acute care settings: a systematic review.
Berger Z, Flickinger TE, Pfoh E, Martinez KA, Dy SM. BMJ Qual Saf. 2014;23:548-555.
Patient engagement is touted as an important tool for detecting adverse events and ensuring safety. This systematic review found that more high-quality evidence is needed to inform practical application of patient engagement programs.
Gunderman R, Lynch J, Harrell H. The Atlantic. September 3, 2013.
This magazine article reports on the unique tension between efficiency mandates and patient-centered care through the example of a cancer patient whose suicidal thoughts might have been missed if not for a curious medical student delving further into the patient's medication concerns during a routine follow-up appointment.
Rosenbaum L. The New Yorker: Elements. August 20, 2013.
This magazine article relates the risks and benefits associated with the 2003 resident work hour limits.
Ofri D. New York Times. July 18, 2013.
In this newspaper piece, a physician describes the pervasive issue of disrespect in health care, its connection to patient safety, and clinicians' responsibility to model respectful behavior.
Gunderman R. The Atlantic. June 5, 2013.
This magazine article highlights the drawbacks of amassing information in electronic medical records, in that it may negatively influence real communication or clinicians' genuine understanding of the patient.
Tools/Toolkit > Multi-use Website
Rockville, MD: Agency for Healthcare Research and Quality; June 2013.
Studies have shown that a surprisingly large proportion of hospitalized patients are not aware of their diagnoses or treatment plan and that their preferences are often not taken into account in advanced care planning. This failure to provide patient-centered care indicates a need for increased patient engagement in safety and quality efforts. This toolkit published by the Agency for Healthcare Research and Quality is designed to help hospitals develop partnerships with patients around improving safety. Developed with input from clinicians and patients, the guide emphasizes four strategies—working with patients as advisors, improving bedside communication, integrating patients and families into shift changes, and using patient input to improve the discharge process. An AHRQ WebM&M perspective by Dr. Saul Weingart discusses the practical challenges of engaging patients in improvement efforts.