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- Communication between Providers 8
- Culture of Safety 2
- Education and Training 6
- Error Reporting and Analysis 8
- Human Factors Engineering 10
- Legal and Policy Approaches 7
- Logistical Approaches 3
- Policies and Operations 4
- Quality Improvement Strategies 8
- Specialization of Care 12
- Teamwork 4
- Clinical Information Systems 3
- Transparency and Accountability 1
- Alert fatigue 1
- Diagnostic Errors 9
- Discontinuities, Gaps, and Hand-Off Problems 8
- Drug shortages 1
- Failure to rescue 3
- Fatigue and Sleep Deprivation 1
- Identification Errors 1
- Medical Complications 4
- Medication Errors/Preventable Adverse Drug Events 8
- Nonsurgical Procedural Complications 2
- Psychological and Social Complications 2
- Surgical Complications 2
- Family Members and Caregivers 2
- Health Care Executives and Administrators 24
Health Care Providers
- Nurses 1
- Non-Health Care Professionals 6
- Patients 21
Search results for "North America"
Partnering with families and patient advocates: another line of defense in adverse event surveillance.
ISMP Medication Safety Alert! Acute Care Edition. August 1, 2019;24.
Having family members or patient advocates present during hospitalizations can help prevent errors. This newsletter article suggests that utilizing this risk prevention strategy in peripheral care areas such as radiology and other testing units could also prevent patient harm. Recommendations to ensure success of this approach include communicating with advocates, encouraging them to speak up, and activating a rapid response to patient deterioration.
Ross C. STAT. May 13, 2019.
Nuisance alarms, interruptions, and insufficient staff availability can hinder effective monitoring and response to acute patient deterioration. This news article reports on how hospital logistics centers are working toward utilizing artificial intelligence to improve clinician response to alarms by proactively identifying hospitalized patients at the highest risk for heart failure to trigger emergency response teams when their condition rapidly declines.
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.
Erich J. EMS World. April 2019;48:26-31.
Air transport service combines risks associated with both aviation and prehospital trauma care. This article discusses the role of human factors in this fast-paced care environment. The author encourages efforts to reduce risks through policy change, purchasing the latest safety equipment, and empowering staff to decline calls when conditions are unsafe.
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.
Daley J. Colorado Public Radio. February 23, 2018.
Innovations in the prescribing of opioids in the emergency department are needed to change practice and help address the opioid crisis. This news article reports the results of a 10-hospital pilot program, the Colorado Opioid Safety Collaborative, which used alternative pain control approaches to reduce opioid prescriptions by an average of 36%. The program builds on multidisciplinary teamwork to modify pain management in the emergency department. An Annual Perspective highlighted opioid misuse as a patient safety challenge.
Hofmann PB, Bagian JP. Patient Saf Qual Healthc. February 20, 2017.
Lewis M. Nautilus. February 9, 2017.
Physicians' decision-making can be diminished when they are tired, distracted, or too narrowly task-focused. This article discusses cognitive biases and other limitations that affect physicians' ability to process information effectively and explores how these factors can contribute to uncertainty and clinical misjudgment.
Hoffman J. New York Times. June 10, 2016.
Overprescribing of opioids for pain management contributes to the growing crisis involving opioid-related harm. This newspaper article reports on one hospital's efforts to avoid opioid use for patients presenting to the emergency department with pain. Alternative treatments included nonnarcotic infusions, nitrous oxide, music therapy, and holistic techniques.
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.
Luthra S. Kaiser Health News. March 1, 2016.
Many emergency departments have recently implemented electronic health records, which has introduced new safety hazards. This news article reports on challenges associated with the growing use of electronic health records in emergency care, including insufficient usability and increased risk of documentation errors.
Shell ER. Sci Am. 2015;313(5):28-29.
ISMP Medication Safety Alert! Acute Care Edition. December 18, 2014;19:1,4.
This newsletter article discusses an adverse drug event involving a patient who died after receiving a neuromuscular blocker instead of a seizure control agent. The preparation error was associated with incorrect labeling. Because neuromuscular blocking agents are considered high-alert medications, more robust administration processes should be employed to reduce the potential for mix-ups.
Dwyer J. New York Times. October 25, 2012.
Dwyer J. New York Times. July 11, 2012:A15.
This newspaper article reports on gaps in communication and a missed sepsis diagnosis that led to a patient's death.
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.
Get a clue: it can be all too easy to make assessment errors in the field; here's some tips to prevent you from making mistakes.
Rubin M. EMS World. 2011;40:57-64.
This article describes how misdiagnosis can occur during emergency assessments due to bias, incomplete data, ineffective communication, and misinterpretation of results.
ED Manag. 2011;23:78-80.
Landro L. Wall Street Journal. May 10, 2011:D3.
This newspaper article reports on efforts to reduce errors in emergency medicine, including improving physician–nurse communication, adopting timeouts before discharge, and using trigger systems.