Narrow Results Clear All
- WebM&M Cases 2
- Study 7
- Audiovisual 5
- Book/Report 5
- Newspaper/Magazine Article 48
- Special or Theme Issue 1
- Glossary 1
- Toolkit 4
- Web Resource 9
- Grant 1
Communication between Providers
- Sbar 1
- Communication between Providers 22
- Culture of Safety 3
Education and Training
- Students 1
- Error Reporting and Analysis 15
- Human Factors Engineering 5
- Legal and Policy Approaches 17
- Logistical Approaches 11
- Quality Improvement Strategies 17
- Specialization of Care 4
- Teamwork 2
- Clinical Information Systems 10
- Transparency and Accountability 1
- Device-related Complications 4
- Diagnostic Errors 11
- Discontinuities, Gaps, and Hand-Off Problems
- Fatigue and Sleep Deprivation 4
- Identification Errors 5
- Medical Complications 6
- Medication Safety 19
- Nonsurgical Procedural Complications 1
- Psychological and Social Complications 3
- Surgical Complications 5
- Ambulatory Care 11
- General Hospitals 14
- Long-Term Care 1
- Outpatient Surgery 1
- Patient Transport 1
- Internal Medicine 21
- Nursing 2
- Pharmacy 5
- Family Members and Caregivers 7
- Health Care Executives and Administrators 31
Health Care Providers
- Nurses 5
Non-Health Care Professionals
- Media 1
Search results for "Patients"
Journal Article > Study
The Ask Me to Explain campaign: a 90-day intervention to promote patient and family involvement in care in a pediatric emergency department.
Tothy AS, Limper HM, Driscoll J, Bittick N, Howell MD. Jt Comm J Qual Patient Saf. 2016;42:281-286.
This study reports on efforts to enhance communication between clinicians and patients in an urban pediatric emergency department. A rapid-change project resulted in significant improvement in patient perceptions of communication—clinicians were perceived as being more sensitive to patients' concerns and displayed better listening behaviors. Poor discharge communication in the emergency department has been linked to safety concerns in prior studies.
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.
Lord T. Patient Saf Qual Healthc. March/April 2012;9:38-41,44.
This article details how miscommunication and lack of patient-centered care contributed to errors that led to the death of a child.
Journal Article > Commentary
Davis Giardina T, Singh H. JAMA. 2011;306:2502-2503.
This commentary discusses a federal proposal to provide patients with direct access to laboratory test results as a tactic to reduce errors.
Journal Article > Commentary
Griffin T. J Perinat Neonatal Nurs. 2010;24:348-353.
This commentary describes nurse change-of-shift reports as a tactic to improve communication with patients and families to promote safe care.
Rockville, MD: Agency for Healthcare Research and Quality. September 29, 2010.
This trio of public service announcements promotes safe medication use, informed discharge, and family and friends as advocates in the hospital.
Tools/Toolkit > Glossary
Chicago, IL: Consumers Advancing Patient Safety; 2009.
This toolkit includes comprehensive information for patients and families to facilitate safe transitions from hospital to follow-up care.
Tools/Toolkit > Government Resource
Leonhardt K, Bonin K, Pagel P. Rockville, MD: Agency for Healthcare Research and Quality; April 2008. AHRQ Publication Nos. 080048.
This AHRQ-funded toolkit outlines how one Midwestern hospital system successfully implemented a patient advisory council. A companion toolkit illustrates how the council worked with the hospital to develop and implement a medication list initiative.
Parker L. USA Today. December 19, 2006.
This article reports on the case of an elderly patient whose advance directive wasn't followed and discusses the impact of this omission.
Holt TE. Men's Health. November 3, 2006.
This series includes articles on "doorway diagnosis" (or a doctor's assessment of a patient before an exam begins), anesthesiologists addicted to painkillers, and medical mistakes in the emergency room.
Geneva, Switzerland: World Health Organization; 2019.
Reducing adverse medication events is a worldwide challenge. This collection of technical reports explores key areas of concern that require action at a system level to improve: high-alert medications, polypharmacy, and medication use at care transitions. Each monograph provides an overview of the topic as well as practical improvement approaches for patients, clinicians, and organizations.
Cullen A. Uitgeverij van Brug: The Hague, The Netherlands; 2019. ISBN: 9789065232236.
Patient stories offer important insights regarding the impact medical errors have on patients and their families. This book shares the author's experience with medical error and spotlights how lack of transparency in European health care can contribute to avoidable process failures that result in patient harm.
Kowalczyk L. Boston Globe. July 29, 2017.
Journal Article > Study
Healthcare professional and patient codesign and validation of a mechanism for service users to feedback patient safety experiences following a care transfer: a qualitative study.
Scott J, Heavey E, Waring J, Jones D, Dawson P. BMJ Open. 2016;6:e011222.
Patients may provide a valuable perspective with regard to safety efforts. In this qualitative study, researchers developed and validated a survey for patients to provide feedback on safety issues about care transfers between different institutions. The authors suggest that further research is necessary to determine the usability of the survey and how best to use the patient feedback obtained.
Aleccia J. Seattle Times. June 18, 2016.
Patients who experience harm while receiving medical care can serve as powerful advocates for patient safety. This news article reports on a patient who became engaged in working to redesign processes to improve patient safety after he became paralyzed from the chest down due to a cascade of communication errors.
Rau J. Washington Post. April 29, 2016.
Transitions in care between inpatient and outpatient settings are an increasing concern for patient safety. Reporting on a fatal medication error that was missed by a patient's pharmacist and home health nurses, this newspaper article discusses various risks associated with hospital-to-home transitions such as insufficient case management and communication.
Landro L. Wall Street Journal. October. 26, 2015.
Journal Article > Study
The Family Caregiver Activation in Transitions (FCAT) tool: a new measure of family caregiver self-efficacy.
Coleman EA, Ground KL, Maul A. Jt Comm J Qual Patient Saf. 2015;41:502-507.
Efforts to improve patient safety during care transitions have had mixed success, possibly due to failure to effectively engage family and caregivers in the transition process. This study reports on the development and validation of a novel survey instrument that measures family and caregivers' preparation and self-efficacy around supporting patients at the time of hospital discharge.
Bond A. New York Times. June 16, 2015.
Clinician communication with patients and families during transitions has been a focus of safety improvement efforts. This newspaper article describes insights from a resident physician regarding how poor communication between teams caring for patients can result in unnecessary care, family discomfort, and confusion for the patient receiving different information among varying teams.
Gabler E. Milwaukee Journal Sentinel. May 15, 2015.
Reporting on weaknesses in laboratory testing methods, this news article discusses patients' experiences with testing errors to illustrate how such failures can contribute to patient harm—such as missed or delayed diagnosis—and raises concerns about insufficient transparency, investigations, and regulations around laboratory facilities with poor processes.