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- Communication Improvement 17
Education and Training
- Students 1
- Error Reporting and Analysis 21
- Human Factors Engineering 7
- Legal and Policy Approaches 30
- Logistical Approaches 1
- Quality Improvement Strategies 7
- Teamwork 1
- Technologic Approaches 8
- Device-related Complications 3
- Diagnostic Errors 34
- Discontinuities, Gaps, and Hand-Off Problems 5
- Identification Errors 6
- Medical Complications 4
- Medication Safety 13
- Nonsurgical Procedural Complications 1
- Overtreatment 1
- Psychological and Social Complications 5
- Surgical Complications 12
- Transfusion Complications 1
- Allied Health Services 1
- Internal Medicine 20
- Nursing 3
- Palliative Care 1
- Pharmacy 7
- Family Members and Caregivers 1
- Health Care Executives and Administrators 7
Health Care Providers
- Physicians 12
- Non-Health Care Professionals 14
Search results for "Patients"
- Cognitive Errors ("Mistakes")
Getting the wrong person's medicine at the pharmacy: easy steps consumers can take to help eliminate these errors.
ISMP Safe Medicine. July/August 2015;13:1-3.
Dispensing errors in the community setting are a frequent source of concern. This newsletter article describes how correctly completed medication orders can inadvertently be given to the wrong patient in the community pharmacy setting and reviews steps patients can take to avoid receiving the incorrect medication.
Cohn J. The Atlantic. March 2013;311:59–67.
This magazine article reports how technology, such as IBM's Watson, can improve the efficiency and accuracy of health care decision making.
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.
US Food and Drug Administration. March 8, 2019.
Errors of commission during complex procedures can contribute to patient harm. Drawing from an analysis of medical device reports submitted to the Food and Drug Administration, this announcement seeks to raise awareness of common adverse events associated with surgical staplers and implantable staples. User-related problems include opening of the staple line, misapplied staples, and staple gun difficulties. Recommendations include ensuring availability of various staple sizes and avoiding use of staples on large blood vessels.
Chisholm P. Health Shots. National Public Radio. February 27, 2019.
Parikh R. MIT Technol Rev. October 23, 2018.
Computerized decision support and artificial intelligence (AI) are being utilized to enhance decision-making in health care. This magazine article explains how artificial intelligence presents clinicians with an opportunity to improve practice by reducing cognitive load when determining appropriate diagnoses and treatment decisions.
Biel L. ProPublica. October 2, 2018.
This news article reports on systemic weaknesses that enabled a surgeon with poor skills to continue to perform procedures after numerous surgical errors that resulted in patient harm. A past PSNet perspective explored the risk of recurring medicolegal events among providers who have received unsolicited patient complaints, faced disciplinary actions by medical boards, or accumulated malpractice claims.
Schulte F, Lucas E, Mahr J. Kaiser Health News and Chicago Tribune. September 5, 2018.
Sepsis is a serious condition that can be fatal if it is not promptly diagnosed and treated. This news article reports on systemic factors in nursing homes such as poor staffing and communication with families that contribute to unmanaged pressure ulcers and sepsis that result in hospital admissions and death. A WebM&M commentary discussed a case involving a patient who had a pressure ulcer and sepsis in long-term care.
O'Loughlin E. New York Times. April 30, 2018.
Large-scale adverse events should lead to system examination and improvement. This newspaper article reports on misread cervical cancer tests that resulted in 208 women receiving false negative results over a 4-year period from a publicly funded smear test program in Ireland and the government inquiry launched in response to this large-scale failure.
Szabo L. Kaiser Health News. October 23, 2017.
Overdiagnosis and overtreatment present a challenge to patient safety. This news article reports on the prevalence of overtreatment among patients with cancer, how it can result in patient harm, and patient stories that illustrate the impact of overtreatment. A past PSNet interview discussed the patient safety implications of diagnostic radiology overuse.
Landro L. Wall Street Journal. September 12, 2017.
Misdiagnosis has gained recognition as an important patient safety problem. This newspaper article reports on several areas of research and improvement efforts that seek to better understand the roots of diagnostic error and design solutions. Strategies discussed include artificial intelligence, lessons learned initiatives, and data-tracking mechanisms.
Mickle K. Glamour Magazine. August 11, 2017.
Martin N, Montagne R. ProPublica and National Public Radio. May 12, 2017.
Maternal mortality is increasing in the United States. This news article reports on this critical safety problem in the context of the preventable death of a patient whose diagnosis of preeclampsia was missed by her providers, despite persistent concerns raised by family about the patient's symptoms.
Whitman E. Mod Healthc. September 25, 2016.
Misidentification of patients can result in problems such as medication administration delays, blood transfusion mismatches, and wrong-patient surgery. This magazine article reviews recent research on this issue and suggests several system approaches for improvement, including the use of patient photos in electronic health records and standardizing patient identification processes.
Journal Article > Commentary
Minnier T, Phrampus P, Waddell L. JAMA. 2016;316:1207-1208.
Describing an incorrect procedure incident which involved placement of a dialysis catheter instead of a central line, this commentary outlines the root causes of the event and how it could have been prevented. A related editorial introduces Performance Improvement, a series of case-based articles intended to support frontline performance improvement efforts.
Cases & Commentaries
- Spotlight Case
- Web M&M
Brittany McGalliard, PharmD; Rita Shane, PharmD; and Sonja Rosen, MD; September 2016
An elderly woman with multiple medical conditions experienced new onset dizziness and lightheadedness. A home visit revealed numerous problems with her medications, with discontinued medications remaining in her pillbox and a new prescription that was missing. In addition, on some days she was taking up to five blood pressure pills, when she was supposed to be taking only two.
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.
Cohen E. CNN. March 24, 2016.
Poor communication regarding medical errors can contribute to patient and family frustration and fear. Reporting on a case involving disclosure of a wrong-site surgery, this news article describes a resolution program to help patients cope after a preventable error. The program includes apology, disclosure, and explanation of what occurred as well as financial compensation.
Journal Article > Study
Meyer AND, Longhurst CA, Singh H. J Med Internet Res. 2016;18:e12.
The frequency of missed and delayed diagnoses is stimulating interest in innovative ways of improving the diagnostic process. This study reports on the initial experience of a crowdsourcing approach to diagnosis. Patients with difficult-to-diagnose symptoms accessed an online program where volunteer case solvers—only 58% of whom worked in medicine in any capacity—engaged in discussion with patients and provided diagnostic suggestions. A majority of patients felt the service was useful and about half would recommend the program.
Epstein H. The Atlantic. November 17, 2015.
Recent emphasis on diagnostic error has raised awareness of the problem. This magazine article discusses how the wide range of diseases to be considered by pediatricians and challenges associated with children's ability to recognize and describe their symptoms contribute to diagnostic complexity in this specialty.