Narrow Results Clear All
Communication between Providers
- Sbar 4
- Communication between Providers 157
- Culture of Safety 34
Education and Training
- Students 1
Error Reporting and Analysis
- Error Reporting 40
Human Factors Engineering
- Checklists 11
- Legal and Policy Approaches 36
- Logistical Approaches 16
- Policies and Operations 1
- Quality Improvement Strategies 70
- Specialization of Care 17
- Teamwork 27
- Clinical Information Systems 33
- Transparency and Accountability 1
- Alert fatigue 2
- Device-related Complications 12
- Diagnostic Errors 24
- Discontinuities, Gaps, and Hand-Off Problems 62
- Drug shortages 2
- Failure to rescue 2
- Fatigue and Sleep Deprivation 3
- Identification Errors 27
- Interruptions and distractions 2
- Medical Complications 14
- Medication Errors/Preventable Adverse Drug Events 62
- Nonsurgical Procedural Complications 4
- Overtreatment 1
- Psychological and Social Complications 26
- Second victims 1
- Surgical Complications 36
- Transfusion Complications 1
- Ambulatory Care 30
- Hospitals 202
- Long-Term Care 3
- Outpatient Surgery 4
- Patient Transport 3
- Psychiatric Facilities 1
- Internal Medicine 62
- Nursing 12
- Pharmacy 58
- Family Members and Caregivers 15
- Health Care Executives and Administrators 154
Health Care Providers
- Nurses 22
- Pharmacists 31
- Physicians 49
Non-Health Care Professionals
- Media 1
- Patients 131
- Europe 1
- United States of America 301
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.
Colino S. Fam Circle. August 2019;132:66,69.
Patients and families can play a role in ensuring care is effective and safe. This news article recommends ways for patients to reduce risk of errors during a hospitalization, including using a patient portal to identify mistakes, asking questions, bringing an advocate, and working with hospitalists as key care partners.
Butcher L. Managed Care. June 2019;28:37-39.
Inconsistent patient name entry practices in electronic health records can contribute to wrong-patient errors. This magazine article reports on the complex nature of addressing patient-matching discrepancies as an economic, privacy, and technical problem. Improvement strategies include the development and adoption of a national identification program and biometric technology. A WebM&M commentary discussed problems associated with name similarities in the electronic patient record.
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.
ISMP Medication Safety Alert! Acute Care Edition. February 28, 2019;24.
Medication warnings inform providers and patients about risks associated with medication use. As with other safety strategies, applying a systems approach to medication warnings can help redirect actions and prevent patient harm. This article describes design, content, and language characteristics of successful medication safety warnings. In addition, specific design and user-centered considerations are included to improve the effectiveness of electronic alerting.
Cierniak KH, Gaunt MJ, Grissinger M. PA-PSRS. Patient Saf Advis. 2018;15(4).
The operating room environment harbors particular patient safety hazards. Drawing from 1137 perioperative medication error reports submitted over a 1-year period, this analysis found that more than half of the recorded incidents reached the patient and the majority of those stemmed from communication breakdowns during transitions or handoffs. The authors provide recommendations to reduce risks of error, including using barcode medication administration, standardizing handoff procedures, and stocking prefilled syringes.
Graham J. Kaiser Health News. November 21, 2018.
Patients can identify errors in their medical records that health care providers may not recognize. This news article highlights the importance of patients correcting seemingly simple mistakes such as name misspellings and phone numbers as these errors can contribute to situations that result in patient harm.
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.
Gipson K. PA-PSRS Pa Patient Saf Advis. 2018 Oct 31;15(suppl 1):39-45.
Peeples L. Pharmacy Practice News. October 10, 2018.
Structured handoffs can reduce communication problems that contribute to medical error. This magazine article reports on how I-PASS implementation can help enhance the quality and completeness of handoffs, highlights the need for pharmacists to be more engaged in handoff improvement, and offers insights for enhancing their role in the process. In a past PSNet interview, Dr. Amy Starmer discussed the implementation and findings of the landmark I-PASS study.
Peskin SM. New York Times. October 4, 2018.
Error disclosures are difficult but important conversations that can have negative consequences for patients, clinicians, and organizations, even when they are done appropriately. This newspaper article offers insights from a doctor who experienced both sides of disclosure, as a physician disclosing an error and as a patient whose physician missed a complication, and discusses how to manage relationships once clinical mistakes are recognized.
Liberatore K. PA-PSRS Patient Saf Advis. 2018;15(3).
Engaging patients and families in patient safety efforts is a key priority in health care. This poll of patients from Pennsylvania explores actions patients are likely to take to ensure their safe care. The results indicate a strong willingness to ask questions to help patients better understand their care, but patients were uncomfortable with raising concerns if they saw clinician behaviors that diminish safety, such as lack of hand hygiene compliance.
Sederstrom J. Drug Topics. September 17, 2018.
Medication errors continue to be a worldwide patient safety challenge that requires both systems and individual practice strategies for improvement. This magazine article describes how pharmacists can address failures associated with processing, dosing, care transitions, and information sharing to prevent medication errors.
Schulte F, Lucas E, Mahr J. Kaiser Health News and Chicago Tribune. September 5, 2018.
Sepsis is a serious condition that can be fatal if it is not promptly diagnosed and treated. This news article reports on systemic factors in nursing homes such as poor staffing and communication with families that contribute to unmanaged pressure ulcers and sepsis that result in hospital admissions and death. A WebM&M commentary discussed a case involving a patient who had a pressure ulcer and sepsis in long-term care.
Howley EK. US News & World Report. September 5, 2018.
Communication failures in health care routinely challenge patient safety. This news article describes characteristics of the hospital environment that affect nurse–physician relationships such as bullying, production pressure, and care complexity. Clarifying team roles and interdisciplinary activities can improve communication in the care environment. Patients are encouraged to have advocates with them to help prevent and address misunderstandings.
Eldred SM. Health Shots. National Public Radio. August 15, 2018.
Using professional interpreters can avert risks of miscommunication due to language barriers between patients and clinicians. This news article discusses how lack of qualified medical interpreters, use of ad hoc interpreters, and poor patient understanding of instructions can contribute to adverse events. A WebM&M commentary explored patient safety issues associated with patient–clinician language differences.
Fetters A. The Atlantic. August 10, 2018.
Women face implicit bias that can affect the safety and effectiveness of their care. Reviewing several high-profile accounts that raised awareness of challenges women experience in health care, this magazine article describes challenges to safe care such as lack of physician attention to patient concerns, misdiagnosis, and preconceptions regarding pain intensity.
R3 Report. June 25, 2018;7:1-2.
Crouch M. Reader's Digest. April 2018.
Involving patients in their care can help improve safety. This magazine article provides 34 tips from leading patient safety experts to assist patients in this role. Tactics include considering a second opinion, bringing an up-to-date medication list, and repeating information back to providers to reduce misunderstandings.
Lamas D. New York Times. March 27, 2018.
Advance care planning can affect patient safety if the information is unheeded, unavailable, or unread. Reporting on a physician's experience with a patient who nearly received an unwanted intubation due to poor electronic health record data quality and design, this newspaper article describes problems associated with lack of standards for advance care planning documentation and the inability to access advance directives.