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Communication between Providers
- Sbar 1
- Communication between Providers 26
- Culture of Safety 15
- Education and Training 25
Error Reporting and Analysis
- Error Reporting 34
Human Factors Engineering
- Checklists 17
Legal and Policy Approaches
- Regulation 11
- Logistical Approaches 6
- Quality Improvement Strategies 27
- Specialization of Care 3
- Teamwork 9
- Technologic Approaches 16
- Transparency and Accountability 4
- Device-related Complications 12
- Diagnostic Errors 2
- Discontinuities, Gaps, and Hand-Off Problems 8
- Fatigue and Sleep Deprivation 1
- Identification Errors 25
- Interruptions and distractions 1
- Medical Complications 27
- Medication Safety 14
- Nonsurgical Procedural Complications 2
- Psychological and Social Complications 6
- Surgical Complications
- Transfusion Complications 2
- Internal Medicine 21
- Nursing 4
- Pharmacy 2
- Family Members and Caregivers 6
- Health Care Executives and Administrators 46
Health Care Providers
- Nurses 10
- Physicians 24
Non-Health Care Professionals
- Media 1
- Patients 96
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.
Hilton K, Anderson A. Harv Bus Rev. May 20, 2019.
This commentary describes how one health system worked to combat resistance to change associated with implementation of a checklist initiative. The success of the program was built on empowering team members to drive the process, clinician motivation to provide safe care, and engaging leadership. A PSNet interview with Lucian Leape discussed surgical safety checklists.
Span P. New York Times. February 1, 2019.
Cognitive and functional decline can occur as individuals age. Concerns have been raised regarding the need to assess skills of aging physicians. This newspaper article reports on the implementation of mandatory evaluation programs to assess competencies of older surgeons and the profession's response to them.
Hixenbaugh M, Ornstein C. Houston Chronicle and Propublica.
This news investigation chronicles a series of incidents in a transplant program that resulted in patient harm. The systemic nature of the problems such as insufficient whistleblower protection, accountability, and follow-up on patient concerns culminated in a change of hospital leadership. A previous PSNet interview with Charles Ornstein discussed the role of media in raising awareness of patient safety issues.
McGrory K, Bedi N. Tampa Bay Times. November 28, 2018.
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.
Jewett C, Alesia M. Kaiser Health News. August 9, 2018.
High-profile failures during office-based procedures have raised awareness of the potential safety hazards of surgery centers and the need for improved oversight. This news article reports on safety events in ambulatory surgical centers and insufficiencies in incident reporting and analysis. Enhanced transparency regarding those failures can enable informed patient decision-making when choosing care providers.
Bruley ME, Arnold TV, Finley E, Deutsch ES, Treadwell JR. PA-PSRS Pa Patient Saf Advis. June 2018;15.
Although surgical fires are considered never events, they continue to occur. This article reports findings from an analysis of 28 operating room fire incidents submitted over a 5-year period to the Pennsylvania Patient Safety Reporting System. Although incidence of surgical fires has significantly decreased since earlier reporting periods, half of the reported events resulted in patient harm. A past WebM&M commentary discussed surgical fires and how to prevent them.
Mukherjee S. New York Times Magazine. May 9, 2018.
Checklists can coordinate action and communication to augment safety, but human and system factors may hinder their effectiveness. This magazine article reports on how the checklist phenomenon evolved into a global patient safety effort and spotlights the impact of human behavior on reliable implementation of checklist programs in different care environments.
Meyer TA, McAllister RK. Pharmacy Practice News. March 19, 2018.
Perioperative adverse drug events are common and understudied. Reporting on the complexity of medication administration during surgery, this news article reviews strategies to reduce risks of surgical adverse drug events. Specific tactics discussed include proactive problem identification, medication reconciliation, high-alert medication process vigilance, verbal order reduction, and information technology optimization.
Hamilton WL. Patient Saf Qual Healthc. July 31, 2017.
Miscommunication during care transitions can contribute to medical errors. This article discusses how handoff communication tools can help to improve reliability of information transfer associated with anesthesia practice. The authors emphasize the importance of standardizing the process of perioperative data collection.
Boodman SG. Kaiser Health News. July 12, 2017.
Baker M. Seattle Times. February 10, 2017.
Reporting on an incident involving a patient who died after a surgery, this news article discusses potential contributing factors in the incident such as concurrent surgeries and failure to consider patient and family concerns. A past WebM&M commentary highlighted the importance of listening to families when they advocate for patients in the hospital.
ISMP Medication Safety Alert! Acute Care Edition. December 1, 2016;21:1-3.
Accidental administration of irrigation solutions are a wrong-route error that can result in harm. This newsletter article reviews factors that contribute to these incidents in the operating room, such as unlabeled solutions, look-alike labeling, and line connection issues. Recommendations to reduce risks include communicating during transitions, safe storage, and immediate labeling.
Sun LH. The Washington Post. October 13, 2016.
Medical devices can contribute to the spread of health care–associated infections. This news article discusses a government report that raises concerns that patients may have been exposed to a deadly bacterial infection related to an essential piece of equipment used in cardiac surgery worldwide. The resulting infection can be difficult to diagnosis as symptoms may remain dormant for months after the initial exposure.
Kowalczyk L. Boston Globe. August 14, 2016.
Certain elements of the ambulatory surgery environment can increase risk of adverse events. Reporting on a series of patient injuries linked to a contracted anesthesiologist at a cataract surgery center, this news article describes how factors such as production pressure and insufficient assessment of contract anesthesiologists' qualifications can contribute to adverse events in outpatient surgery.
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.
Rice S. Mod Healthc. January 23, 2016.
Abelson J, Saltzman J, Kowalcyzk L, Allen S. Boston Globe. October 26, 2015.
Scheduling concurrent surgeries can have negative effects on staff and patients. This investigative news article explores the practice of overlapping procedures at a leading hospital, potential risks associated with double-booked cases, lack of transparency with patients involved, as well as the potential impact on patient safety.
Luthra S. Kaiser Health News. July 14, 2015.