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Communication between Providers
- Sbar 1
- Communication between Providers 5
- Culture of Safety 1
- Education and Training 11
- Error Reporting and Analysis 6
- Human Factors Engineering 4
- Legal and Policy Approaches
- Logistical Approaches 2
- Quality Improvement Strategies 7
- Specialization of Care 1
- Teamwork 2
- Technologic Approaches 5
- Transparency and Accountability 1
- Device-related Complications 1
- Discontinuities, Gaps, and Hand-Off Problems 2
- Identification Errors 6
- Medical Complications 1
- Medication Errors/Preventable Adverse Drug Events 7
- Psychological and Social Complications 3
- Surgical Complications 7
Search results for "Hospitals"
Dubeck D. PA-PSRS Patient Saf Advis. September 2014;11:93-101.
Research has documented a substantial learning curve for surgeons as they develop skills to use robotic technologies. Drawing from data submitted to the Pennsylvania Patient Safety Authority, this article analyzes the 722 safety events involving robotic-assisted surgery reported since 2005—approximately 75% of these incidents did not result in harm but 10 patient deaths were recorded—and discusses the challenges introduced as robotic-assisted surgery becomes accepted as standard surgical practice.
Bernhard B, Kohler J. St. Louis Post-Dispatch. August 1, 2010:A1
In the context of system failures that contributed to the death of a patient, this newspaper article describes how never events are rarely publicized, even though hospital inspection reports are public records.
Stein L. St. Petersburg Times. June 21, 2010.
Reporting on wrong-site surgeries in Florida hospitals, this newspaper article describes how timeouts have changed the nature and frequency of surgical errors.
Quintero F. Orlando Sentinel. June 16, 2010;A1.
This newspaper article reports how one hospital system introduced advanced training programs to ensure safe use of surgical robots.
Leape LL. Perspect Health Reform. New York, NY: The Commonwealth Fund; March 17, 2010.
Of three approaches to enhancing patient safety—regulation/accreditation, financial incentives, and public reporting—this perspective, written by the father of the modern patient safety movement, details how public reporting holds the most potential to stimulate improvement.
Sandrick K. Trustee. November 2009.
This article discusses how physician disrespect, harassment, and physical intimidation affect staff morale, retention, and team communication. The piece also offers suggestions for board members and hospital leadership on how to address disruptive individuals.
ISMP Medication Safety Alert! Acute Care Edition. October 10, 2008;13:1-3.
Reporting that recalled medications were found in hospital pharmacies, this article describes recommendations to improve the process for removing recalled products.
Kowalczyk L. The Boston Globe. August 10, 2008;Metro section:1A.
This article describes how physician outbursts can affect patient safety and discusses a new Joint Commission policy that supports actions against providers who engage in disruptive behavior.
ISMP Medication Safety Alert! Acute Care Edition. July 3, 2008;13:1-3.
This article reports on the potentially fatal error of administering epidural medications intravenously and provides guidelines to safeguard against such epidural–IV route mix-ups.
Ostendorff J, Bompey N. Asheville Citizen-Times. March 9, 2008;News section:1A.
This article reports on system errors that caused a hospital in North Carolina to lose federal funding.
Associated Press. MSNBC. November 27, 2007.
This news article reports repeated incidents of wrong-side surgery at the same facility, and state and hospital reactions to the errors.
Ostrov BF. San Jose Mercury News. October 26, 2007;Local section:1B.
This article reports that, despite facing state sanctions and fines for its role in three fatal medication errors since 2004, a violating hospital was slow to retrain its pharmacy technicians.
Kowalczyk L. Boston Globe. October 26, 2007;Metro section:1A.
This article investigates the causes of surgical errors reported in recent years by Massachusetts hospitals, and identifies team training and instrument bar-coding as solutions for improvement.
Paul R. Drug Topics. September 17, 2007;151:10.
This article reports on an error for which criminal charges were filed against the pharmacist and his license was revoked, prompting concern from pharmacy experts that such action could discourage reporting.
ISMP Medication Safety Alert! Acute Care Edition. September 6, 2007;12:1-4.
This article analyzes a lethal error involving TPN (total parenteral nutrition), in which dosing and compounding were based on incorrect order entry, and provides recommendations to prevent similar errors.
Wachter RM. Los Angeles Times. July 1, 2007:M1.
Recently, California health officials have argued to revoke the license of King-Harbor Hospital, owing to concerns about patient safety. In this op-ed piece, the author suggests that this urban hospital is unable to provide reliable and safe care to its patients despite repeated attempts to improve the organization.
Fernandez J. Drug Topics. May 7, 2007.
This article discusses a chemotherapy overdose that led to a child's death and the punitive measures taken against the pharmacist involved.
Kowalczyk L. Boston Globe. April 21, 2007:B1.
This article reports on the results from Joint Commission site inspections of five Boston-area hospitals.
Shorr AS. Healthc Exec. March-April 2007;22:19, 21-22, 24, 26.
The author discusses executive accountability for patient safety and active involvement in creating a patient-centric culture.
Wahlberg D. Wisconsin State Journal. July 22, 2006:A1.
This article reports on a federal warning issued to a hospital after a medication error led to the death of a 16-year-old girl.