Narrow Results Clear All
- Communication Improvement 10
- Culture of Safety 4
- Education and Training 8
- Error Reporting and Analysis 14
- Human Factors Engineering 13
- Legal and Policy Approaches 11
- Logistical Approaches 4
- Quality Improvement Strategies 7
- Specialization of Care 4
- Clinical Information Systems 6
- Transparency and Accountability 2
- Device-related Complications 7
- Diagnostic Errors 7
- Discontinuities, Gaps, and Hand-Off Problems 2
- Identification Errors 2
- Medical Complications 4
- Medication Errors/Preventable Adverse Drug Events 29
- MRI safety 1
- Nonsurgical Procedural Complications 1
- Surgical Complications 5
- Internal Medicine 10
- Pharmacy 13
- Family Members and Caregivers 4
- Health Care Executives and Administrators 15
Health Care Providers
- Nurses 4
- Non-Health Care Professionals 8
- Patients 25
Search results for "North America"
Gabler E. New York Times. May 31, 2019.
Pediatric cardiac surgery is highly technical and risky. This newspaper article reports on a poorly performing pediatric cardiac surgery program, concerns raised by staff, and insufficient response from organizational leadership. Lack of data transparency, insufficient resources, and limited program capabilities to support a complex program contributed to poor outcomes for pediatric patients.
ISMP Medication Safety Alert! Acute Care Edition. April 25, 2019.
Newborns assigned temporary names are at increased risk for patient misidentification and wrong-patient errors. This newsletter article reports on the role of electronic health records in newborn misidentification and the unintended consequences associated with a Joint Commission set of recommendations to reduce risk.
McGrory K, Bedi N. Tampa Bay Times. November 28, 2018.
Mohr H, Weiss M. Associated Press. November 27, 2018.
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.
R3 Report. June 25, 2018;7:1-2.
Kowalczyk L. Boston Globe. May 27, 2018.
Pediatric patients are particularly vulnerable to medication errors. This news article reports on serious medication errors that occurred at Children's Hospital in 2017, the underlying system failures that contributed to the incidents, and challenges to implementing new policies meant to prevent similar errors.
Quick Safety. March 27, 2018;(40):1-2.
Falls are a common patient safety concern for adults but are rarely discussed as a threat to newborn safety. This newsletter article provides a definition for a newborn fall or drop, highlights factors that increase risks of such incidents, and offers recommendations to augment safety such as rounding to monitor parent fatigue and reporting of events to inform improvements.
Furfaro H. Wall Street Journal. September 25, 2016.
Medication errors in pediatric care are common in the hospital and at home. This newspaper article reports on problems associated with medication safety among pediatric patients and highlights several tools both clinicians and parents can use to enhance safety when administering medicine to children, including dosage calculators and pictures depicting medication administration processes.
ISMP National Vaccine Errors Reporting Program: one in three vaccine errors associated with age-related factors.
ISMP Medication Safety Alert! Acute Care Edition. July 28, 2016;21:1-6.
Vaccine errors can hinder immunization efforts in the United States. Summarizing nearly 4 years of data submitted to the ISMP Vaccine Errors Reporting Program, this newsletter article highlights age-related factors that surfaced in the analysis and recommends strategies for improvement such as patient education and age verification.
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.
Grissinger M. PA-PSRS Patient Saf Advis. September 2015;12:96-102.
This article analyzed more than 4000 pediatric medication errors to determine contributing factors, including lack of patient information, drug name or packaging confusion, and IV pump and IV line mix-ups. Improvement efforts should focus on individualized ready-to-deliver medications as an error reduction strategy.
ISMP Medication Safety Alert! Acute Care Edition. June 4, 2015;20:1-6. July 2, 2015;20:1-5.
Hospitalized children are susceptible to medication errors due to difficulty with weight-based dosing and knowing when patients are experiencing adverse drug effects. This two-part newsletter article reports online survey responses from nearly 1500 clinicians regarding the use of error prevention strategies at the prescribing, dispensing, and administering phases of pediatric medication delivery. Safety practices such as the use of metric units have become well established over a 15-year period, yet practices involving the active role of pharmacists on care units need improvement.
Brown E, Lin RG II R, Xia R. Los Angeles Times. January 26, 2015.
In light of the recent outbreak of measles in California, this newspaper article reports on how lack of familiarity with measles among clinicians can contribute to diagnostic errors and spread of the disease.
Connor M, Wayman KI, Garcia C, Fischer PR; Consortium for Maximizing Family-Centered Care. Patient Saf Qual Healthc. September/October 2014;11:36,38-40,42.
Patients are increasingly encouraged to take an active role in their own safety during hospital care. Describing a near miss of a medication error, this magazine article examines elements of effective disclosure and how engaging patients and their families can contribute to error investigations and safety improvement.
Catalanello R. The Times-Picayune. April 15, 2014.
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.
Consumer Reports. January 26, 2012.
Consumer Reports analyzed publicly reported infection rates for 92 pediatric intensive care units (ICUs) and found that hospital-acquired infections were 20% higher in pediatric ICUs than in adult ICUs.
Landro L. Wall Street Journal. January 17, 2012:D1.
This newspaper article discusses second opinions as a tactic for catching diagnostic errors.
Gilk T, Latino RJ. Patient Saf Qual Healthc. November/December 2011;8:22-23,26-29.
Describing a case of accidental patient death in an MRI suite, this article reviews a root cause analysis of the event and notes that no regulatory efforts have been implemented to improve MRI safety in the 10 years following the incident.