Narrow Results Clear All
- Communication Improvement 3
- Culture of Safety 1
- Education and Training 1
- Error Reporting and Analysis 4
- Human Factors Engineering 2
- Legal and Policy Approaches 8
- Logistical Approaches 1
- Quality Improvement Strategies 3
- Specialization of Care 1
- Technologic Approaches 2
- Transparency and Accountability 1
- Diagnostic Errors 4
- Discontinuities, Gaps, and Hand-Off Problems 3
- Identification Errors 1
- Medication Safety 4
- Psychological and Social Complications 3
- Second victims 1
- Surgical Complications 1
Search results for "Cognitive Errors ("Mistakes")"
- Cognitive Errors ("Mistakes")
- Policy Makers
Gordon M. Health Shots. National Public Radio. April 10, 2019.
Punitive responses to medical errors persist despite continued efforts to reduce them. This news article reports on an incident involving the mistaken use of a neuromuscular blocking agent that resulted in the death of a patient, the prosecution of the nurse who made the error, and systemic and human factors that contribute to similar events.
Another round of the blame game: a paralyzing criminal indictment that recklessly "overrides" just culture.
ISMP Medication Safety Alert! Acute Care Edition. February 14, 2019;24.
Journal Article > Commentary
Ost S. J Med Ethics. 2019;45:151-155.
Labeling medical negligence as a criminal act can affect transparency and disclosure behaviors across professional health care communities. This commentary discusses two high-profile cases from the United Kingdom to explore the appropriateness of assigning criminality in either instance—one centered on human error that contributed to the death of a child and the other involved negligent actions but resulted in no permanent patient harm.
Journal Article > Commentary
Berenson R, Singh H. Health Aff (Millwood). 2018;37:1828-1835.
The use of value-based payment models to advance quality improvement in health care has yet to be applied to improving diagnosis. This commentary suggests that refining the Medicare coding, developing new alternative payment models, and utilizing timeliness and accuracy as payment triggers could drive tracking and analysis of weaknesses in diagnosis to catalyze improvements in diagnostic performance.
The Moore Foundation provides free access to this article.
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.
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; January 2015. Report No. OEI-01-13-00400.
A widely-reported meningitis outbreak in the United States uncovered quality and safety issues associated with the use of compounded sterile preparations. This publication describes an analysis of five accreditation organizations and their ability to provide oversight and inspection of Medicare hospitals that contract with compounding entities. The authors offer recommendations to help hospitals determine if their compounded sterile preparations contracts ensure products are prepared safely for use, including targeted training for surveyors related to compounding and improved contracting processes.
Journal Article > Review
Wu AW, Kavanagh KT, Pronovost PJ, Bates DW. J Patient Saf. 2014;10:181-185.
In light of an unreported conflict of interest that might have affected recommendations for chlorhexidine use to reduce risk of central line–associated infections, this review examines articles written or coauthored by Dr. Charles Denham to determine whether undeclared conflicts of interest could have influenced conclusions, selections, and recommendations in published research. The authors emphasize the need to identify and address conflicts of interest and outline strategies to reduce risk of undisclosed conflicts which may in turn affect validity of published evidence.
Journal Article > Study
Am I my brother's keeper? A survey of 10 healthcare professions in the Netherlands about experiences with impaired and incompetent colleagues.
Weenink JW, Westert GP, Schoonhoven L, Wollersheim H, Kool RB. BMJ Qual Saf. 2015:24:56-64.
In this survey study, one-third of respondents reported an experience with an impaired or incompetent colleague within the last year. One limitation to the survey findings was the low 28% response rate, but the authors note that even if all non-respondents had no such encounters, the results suggest at least 9% of health care professionals have dealt with impaired or incompetent colleagues.
Interim Report: Review of VHA's Patient Wait Times, Scheduling Practices, and Alleged Patient Deaths at the Phoenix Health Care System.
Washington, DC: VA Office of the Inspector General; May 28, 2014. Report No. 14-02603-178.
The Veterans Health Administration has earned widespread praise for improving quality of care during the past decade, but this report by the Veterans Affairs (VA) Office of the Inspector General exposes serious problems within the Phoenix VA facility, which may be representative of system-wide issues with access to care. Even though the facility officially reported average wait times of only 24 days, the investigation found that veterans typically waited nearly 4 months for a new primary care appointment. This discrepancy was due to systematic manipulation of the scheduling system—more than 1700 patients had requested an appointment but were never enrolled on the waiting list for scheduling. Because wait times for primary care appointments were a VA quality metric, clinics likely resorted to gaming the system to appear to achieve their targets. The report indicates that evidence of inappropriate manipulation of the scheduling process has been found at many other VA facilities as well. The study did not formally address whether these delays in care directly led to deaths or preventable harm. An investigation of specific cases of deaths among patients who were waiting for appointments is ongoing and is expected to be released later this year.
Berenson RA, Upadhyay D, Kaye DR. Washington, DC: Urban Institute. Princeton, NJ: Robert Wood Johnson Foundation; 2014.
This comprehensive policy brief emphasizes the importance of addressing diagnostic errors through health policy change. The report explores the role of missed and delayed diagnosis in malpractice claims and preventable harm to patients. The authors note the lack of attention to diagnosis in the seminal To Err is Human report. They outline several strategies to detect and characterize diagnostic errors, including patient and provider surveys, case review, voluntary reporting, claims review, audits, and trigger tools in electronic medical records. To enhance timely and accurate diagnoses, the report advocates for increasing research funding, greater government oversight, instituting formal diagnostic feedback mechanisms, and payment and medical education reform.
Paterson R. Auckland, New Zealand: Office of the Health and Disability Commissioner; April 24, 2007.
This report analyzes an incident of medication error that led to a patient's death, discusses the subsequent actions taken by the health board, and calls for a coordinated approach to medication reconciliation in New Zealand.
Cases & Commentaries
- Web M&M
Jeanne Mandelblatt, MD, MPH; February 2004
A physician who does not accept Medicaid turns away a woman needing evaluation for 2 years of profuse vaginal bleeding. She later presents to the ED, where examination reveals invasive cervical cancer.
Cases & Commentaries
- Web M&M
Donna L. Washington, MD, MPH; January 2004
A triage nurse instructed by a physician to immediately bring a febrile child, who was possibly dehydrated, to the treatment area is stopped by the charge nurse, citing overcrowding. The parents seek treatment elsewhere; upon arrival, the child is in full arrest.