Narrow Results Clear All
- WebM&M Cases 1
- Perspectives on Safety 4
- Commentary 11
- Study 4
- Audiovisual 33
- Book/Report 15
- Legislation/Regulation 7
- Newspaper/Magazine Article 213
- Special or Theme Issue 3
- Toolkit 1
- Web Resource 21
- Award 4
- Grant 2
- Meeting/Conference 2
- Press Release/Announcement 3
Communication between Providers
- Sbar 1
- Communication between Providers 10
- Culture of Safety 14
Education and Training
- Students 1
Error Reporting and Analysis
- Error Reporting 72
- Human Factors Engineering 18
Legal and Policy Approaches
- Regulation 52
- Logistical Approaches 6
- Policies and Operations 1
- Quality Improvement Strategies 46
- Teamwork 4
- Clinical Information Systems 13
- Transparency and Accountability 7
- Device-related Complications 14
- Diagnostic Errors 27
- Discontinuities, Gaps, and Hand-Off Problems 17
- Drug shortages 7
- Failure to rescue 1
- Fatigue and Sleep Deprivation 4
- Identification Errors 12
- Medical Complications 40
- Medication Errors/Preventable Adverse Drug Events 33
- MRI safety 1
- Nonsurgical Procedural Complications 5
- Overtreatment 1
- Psychological and Social Complications 11
- Surgical Complications 50
- Transfusion Complications 3
- Ambulatory Care 32
- General Hospitals 50
- Long-Term Care 8
- Outpatient Surgery 8
- Psychiatric Facilities 1
- Allied Health Services 1
- Internal Medicine 83
- Pediatrics 15
- Nursing 10
- Pharmacy 21
- Family Members and Caregivers 18
- Health Care Executives and Administrators 87
Health Care Providers
- Nurses 5
- Physicians 17
Non-Health Care Professionals
- Media 7
- Australia and New Zealand 3
- Europe 10
- Canada 8
Search results for "Patients"
- Legal and Policy Approaches
St. Paul, MN: Minnesota Department of Health; March 2019.
The National Quality Forum has defined 29 never events—patient safety problems that should never occur, such as wrong-site surgery and patient falls. Since 2003, Minnesota hospitals have been required to report such incidents. The 2018 report summarizes information about 384 adverse events that were reported and found pressure ulcers and invasive procedure events increased, while fall-related deaths decreased. Reports from previous years are also available.
Jaffe I, Renincasa R. Morning Edition. National Public Radio. December 8–9, 2014.
Overprescribing of medications is a common problem in nursing homes. This two-part radio segment reports on the inappropriate use of antipsychotic medications as a chemical restraint for patients with dementia. The first part introduces the issue and includes insights from families that have experienced harm due to the practice. The second segment discusses programs that the Centers for Medicare and Medicaid Services has put in place to address the problem through a more patient-centered approach to care and suggests strengthening penalties against organizations that overuse antipsychotics.
Harrow, Middlesex, UK: The Patients Association; 2013.
This publication provides patient and family accounts of incidents involving inadequate care or harm and highlights the need for improvements recommended in a National Health Services report.
Teegardin C. Atlanta Journal-Constitution. April 28, 2013.
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.
Sanders L. New York Times Magazine. March 18, 2012.
This interactive magazine feature takes readers through the decision-making process in a case involving diagnostic error.
Gupta S. New York, NY: Grand Central Publishing; 2012. ISBN: 9780446583855.
To illustrate how physicians learn from mistakes, this novel (written by CNN medical correspondent Dr. Sanjay Gupta) explores the impact of a medical error on surgeons at one hospital.
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.
Allen M. Washington Monthly. March/April 2011.
This magazine article reports on medical errors in the United States health care system and discusses transparency as a tactic to improve patient safety.
Bogdanich W, Rebelo K. New York Times. December 28, 2010;A1.
This article explores inaccuracy of dosage, lack of protocol adherence, and absence of transparency as trends that hinder learning from radiological adverse events.
Austin, TX: Texas Medical Institute for Technology and the Quaid Foundation; 2010.
This documentary reports on families affected by medical errors; it includes the story of a high-profile heparin overdose and how it transformed the family of actor Dennis Quaid into advocates for patient safety.
Kauffman M, Altimari D. The Hartford Courant. November 15, 2009;Final:A1.
This newspaper article reports that a Connecticut law intended to make hospital errors more transparent has had the opposite effect by making it easier for hospitals to limit publicly available information on adverse events.
Tools/Toolkit > Multi-use Website
Institute for Healthcare Improvement.
This website provides resources for promoting patient safety during Patient Safety Awareness Week. The 2019 observance will be held March 10–16 and will focus on improving safety in the ambulatory setting. A free webcast on March 13, 2019 between 2:00–3:00 PM (Eastern) will discuss outpatient safety improvement tactics, with Dr. Tejal Gandhi, Dr. Jeff Brady, and Lisa Shilling as featured speakers.
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.
Kapadia R. Smart Money. October 2006;15:112-114.
This article provides tips for consumers to help keep their hospital care as safe and hassle-free as possible.
Web Resource > Multi-use Website
8230 Old Courthouse Road, Suite 420, Tysons Corner, VA.
A comprehensive systems-focused approach must be employed in the hospital and at home to ensure reliable medication use. This institute supports multistakeholder activities to enhance policy and education throughout health care to optimize and improve medication practices of caregivers, families, pharmacists, and clinicians.
Web Resource > Multi-use Website
American Hospital Association.
Maternal harm is a patient safety concern that is increasingly prioritized in regulatory and care delivery environments. This website provides tools, policies, news articles, case studies, and information for patients and families to inform efforts to protect mothers and infants across geographic regions.
Lives Lost, Lives Saved: An Updated Comparative Analysis of Avoidable Deaths at Hospitals Graded by The Leapfrog Group.
Austin M, Derk J. Baltimore, MD: Armstrong Institute for Patient Safety and Quality, and Johns Hopkins Medicine; May 2019.
Measures help track gaps in process and evidence of safety improvements. This white paper examines the performance of hospitals receiving Hospital Safety Grades and the relationship between high-level recognition and preventable harm. The report estimates that a substantial number of lives could have been saved if performance metrics had been met, but concludes that even high-performing hospitals exhibit areas in need of improvement.
Legislation/Regulation > Colorado Legislation
Pettersen B, Tate J, Tipper K, McKean H. Colorado Senate Bill 19-201.
Communication-and-resolution mechanisms are seen as important approaches to improving transparency and healing after an adverse event. This state bill, referred to as the "Colorado Candor Act," protects conversations between organizations, clinicians, patient, and families from legal discoverability and outlines criteria to guarantee that protection.
Palmer J. Patient Saf Qual Healthc. May/June 2019.
Organizations must learn from adverse events to prevent similar incidents. Reporting on lessons to be learned from the cascade of failures connected with the preventable death of a patient during an acute asthma attack at the door of a hospital emergency department, this magazine article outlines the importance of effective signage, appropriate security staff placement, and acceptance of the responsibility for failure.