Narrow Results Clear All
- Patient Safety Primers 3
- WebM&M Cases 353
Perspectives on Safety
- Interview 22
- Perspective 15
- Commentary 476
- Review 220
- Study 1050
- Slideset 3
- Book/Report 104
- Legislation/Regulation 26
- Newspaper/Magazine Article 356
- Newsletter/Journal 3
- Special or Theme Issue 30
- Toolkit 18
- Web Resource 117
- Award 5
- Bibliography 1
- Clinical Guideline 4
- Grant 1
- Meeting/Conference 14
- Press Release/Announcement 34
Communication between Providers
- Sbar 7
- Communication between Providers 462
Culture of Safety
- Just Culture 25
Education and Training
- Simulators 66
- Students 53
Error Reporting and Analysis
- Error Analysis 478
- Error Reporting 333
Human Factors Engineering
- Checklists 146
Legal and Policy Approaches
- Regulation 22
- Logistical Approaches 113
- Policies and Operations 15
Quality Improvement Strategies
- Benchmarking 16
- Reminders 25
- Research Directions 11
- Specialization of Care 84
- Teamwork 87
- Clinical Information Systems 332
- Computer-Assisted Therapy 4
- Transparency and Accountability 39
- Alert fatigue 16
- Device-related Complications 132
- Diagnostic Errors 612
Discontinuities, Gaps, and Hand-Off Problems
- Missed Care 18
- Drug shortages 7
- Failure to rescue 11
- Fatigue and Sleep Deprivation 20
- Identification Errors 133
- Inpatient suicide 3
- Interruptions and distractions 59
- Delirium 5
- Medication Errors/Preventable Adverse Drug Events 783
- MRI safety 4
Nonsurgical Procedural Complications
- Cardiology 12
- Overtreatment 13
- Psychological and Social Complications 137
- Second victims 23
- Surgical Complications 358
- Transfusion Complications 17
- Home Care 23
- Operating Room 345
- General Hospitals 800
- Long-Term Care 37
- Outpatient Surgery 34
- Patient Transport 28
- Psychiatric Facilities 14
- Allied Health Services 10
- Dentistry 4
- Anesthesiology 111
- Critical Care 142
- Dermatology 17
- Gynecology 61
- Cardiology 74
- Geriatrics 77
- Hematology 19
- Medical Oncology 101
- Nephrology 17
- Pulmonology 20
- Neurology 45
- Obstetrics 58
- Pediatrics 238
- Primary Care 111
- Radiology 92
- Nursing 243
- Palliative Care 7
- Pharmacy 284
- Family Members and Caregivers 37
Health Care Executives and Administrators
- Nurse Managers 203
- Risk Managers 248
Health Care Providers
- Nurses 267
- Pharmacists 129
- Physicians 623
Non-Health Care Professionals
- Educators 255
- Engineers 44
- Media 2
- Patients 240
- Africa 5
- China 4
- Australia and New Zealand 102
- Central and South America 11
- United Kingdom 239
- Canada 116
United States of America
United States Federal Government
- Department of Health and Human Services (HHS) 72
- United States Federal Government 104
Search results for "Active Errors"
- Active Errors
Web Resource > Multi-use Website
ClinfoWiki: The Clinical Informatics Wiki.
This wiki article includes a definition of computer-based provider order entry and other information, such as system elements, implementation tips, and unintended consequences.
Hoenig LJ. Med Econ. 2006 Jun 2;83:45-46.
The author discusses the importance of thorough discharge examinations.
Journal Article > Study
Tucker AL, Spear SJ. Health Serv Res. 2006;41:643-662.
This study discovered that nurses experienced more than eight work system failures during an 8-hour shift. Investigators combined primary observation with interview and survey methods to understand the role work system failures play on nurse effectiveness. The most frequent failures identified involved medications, orders, supplies, staffing, and equipment. In addition to operational failures that delayed productivity, a large number of reported work interruptions contributed to the study findings. The authors advocate for continued efforts to differentiate between tactics taken by bedside nurses to prevent error with tactics that result from the system (eg, interruptions), which often put patients at risk for error.
Journal Article > Commentary
Wojcieszak D, Banja J, Houk C. Jt Comm J Qual Patient Saf. 2006;32:344-350.
The authors describe the work of The Sorry Works! Coalition, which aims to minimize the stress and cost associated with medical error by promoting full disclosure and apology.
Baltimore, MD: Centers for Medicare & Medicaid Services (CMS) Office of Public Affairs; May 18, 2006.
This fact sheet provides information regarding the Centers for Medicare and Medicaid Services' initiative to better understand and minimize never events.
Special or Theme Issue
The 13 articles in this special issue cover topics on the role of ergonomics in patient safety.
Meeting/Conference > District of Columbia Meeting/Conference
Society to Improve Diagnosis in Medicine. November 10-14, 2019; Hyatt Regency Washington, Washington DC.
Diagnostic error reduction continues to gain momentum in the research and frontline patient safety communities. This annual conference will focus on the theme, "Shaping Policy, Improving Practice" to discuss physical examination, patient partnership, and political advocacy as strategies to improve diagnosis. Featured speakers include Dr. Shantanu Agrawal, Dr. Helen Burstin and Dr. David Newman-Toker.
Meeting/Conference > Massachusetts Meeting/Conference
Harvard Medical School. November 6-7, 2019; Wyndham Boston Beacon Hill, Boston, MA.
This multidisciplinary conference will offer insights from safety leaders about applying strategies and guidelines to quality and safety improvement in the acute care setting. The session will cover various topics of interest to professionals who work in the field, including radiation safety, care redesign, and leadership skill development.
Meeting/Conference > Canada Meeting/Conference
Canadian Patient Safety Institute. September 12, 2019; 12:00–1:00 PM (Eastern).
Structured approaches to manage negative psychological consequences of medical errors on health care professionals, patients, and families are important for emotional healing and organizational learning. This webinar is part of a series of discussions on peer support efforts for Canadian health care workers.
National Quality Forum.
Cases & Commentaries
- Spotlight Case
- Web M&M
Mythili P. Pathipati, MD, and James M. Richter, MD; August 2019
An elderly man had iron deficiency anemia with progressively falling hemoglobin levels for nearly 2 years. Although during that time he underwent an upper endoscopy, capsule endoscopy, and repeat upper endoscopy and received multiple infusions of iron and blood, his primary physician maintained that he didn't need a repeat colonoscopy despite his anemia because his previous colonoscopy was negative. The patient ultimately presented to the emergency department with a bowel obstruction, was diagnosed with colon cancer, and underwent surgery to resect the mass.
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.
Cases & Commentaries
- Web M&M
Michael J. Barry, MD, and Marc B. Garnick, MD; August 2019
Referred to urology for a 5-year history of progressive urinary frequency, nocturnal urination, and difficulty initiating a stream, a man had been reluctant to seek care for his symptoms because his father had a "miserable" experience with treatment for the same condition. A physician assistant saw him at that first visit and ordered a PSA test (despite the patient's expressed views against PSA testing) and cystoscopy (without explaining why it was needed), and urged the patient to self-catheterize (without any instructions on how to do so). The patient elected not to follow up with the tests because of this negative interaction. Ten weeks later, he sought care from a nurse practitioner at his primary care provider's office where his blood pressure and creatinine levels were found to be markedly elevated, 2L of urine were drained via catheter, and he was admitted to the hospital for renal failure.
Cases & Commentaries
- Web M&M
Yi Lu, MD, PhD, and Douglas Salvador, MD, MPH; August 2019
A woman with a history of prior spine surgery presented to the emergency department with progressive low back pain. An MRI scan of T11–S1 showed lumbar degenerative joint disease and a small L5–S1 disc herniation. She was referred for physical therapy and prescribed muscle relaxant, non-steroidal anti-inflammatories, and pain relievers. Ten days later, she presented to a community hospital with fever, inability to walk, and numbness from the waist down. Her white blood cell count was greater than 30,000 and she was found to be in acute renal and liver failure. She was transferred to a neurosurgery service at an academic hospital when an MRI revealed a T6–T10 thoracic epidural abscess.
Legislation/Regulation > Sentinel Event Alerts
Sentinel Event Alert. July 30, 2019;(61):1-5.
Anticoagulant medications are known to be high-risk for adverse drug events. Although direct oral anticoagulants (DOACs) require less monitoring than warfarin, they are still associated with an increased risk of patient harm if not prescribed and administered correctly. The Joint Commission has issued a new sentinel event alert to raise awareness of the risks related to DOACs, and in particular, the challenges associated with stopping bleeding in patients on these medications. The alert suggests that health care organizations develop patient education materials, policies, and evidence-based guidelines to ensure that DOACs and reversal agents are used appropriately. A past WebM&M commentary discussed common errors related to the use of DOACs.
Journal Article > Study
Aaronson EL, Quinn GR, Wong CI, et al. J Healthc Risk Manag. 2019 Jul 23; [Epub ahead of print].
Malpractice risk in the outpatient setting is significant and claims often involve missed and delayed diagnoses. This retrospective study examined diagnostic error claims in outpatient general medicine to identify characteristics and causes of cancer misdiagnoses. Similar to a prior study, investigators found that missed cancer diagnosis is the leading type of diagnostic error in primary care, constituting nearly half of closed diagnostic claims. Contributing factors included failure or delay in test ordering or consultation. These findings suggest that improving test results management and consultative processes may reduce malpractice risk related to outpatient diagnosis. A previous WebM&M commentary discussed an incident involving a missed diagnosis of spinal cord injury in primary care.
Journal Article > Study
Influence of doctor–patient conversations on behaviours of patients presenting to primary care with new or persistent symptoms: a video observation study.
Amelung D, Whitaker KL, Lennard D, et al. BMJ Qual Saf. 2019 Jul 20; [Epub ahead of print].
Despite many advances in cancer treatment, delays in cancer diagnosis cause substantial morbidity and mortality. System factors like difficulty obtaining appointments contribute to late cancer diagnoses. Timely cancer diagnosis also requires that patients and physicians communicate effectively about next steps in the workup of symptoms. This qualitative study recorded videos of patient–physician interactions and found that 31% of the time, doctors and patients did not align in their perception of the seriousness of a given symptom. The authors theorized that misalignment leads to missed follow-up testing and deterioration in patient–physician trust. A WebM&M commentary described how the cost of a diagnostic test led to a late diagnosis of colon cancer.
Society to Improve Diagnosis in Medicine.
Journal Article > Study
Serious misdiagnosis-related harms in malpractice claims: the "Big Three"—vascular events, infections, and cancers.
Newman-Toker DE, Schaffer AC, Yu-Moe CW, et al. Diagnosis (Berl). 2019;227-240.
Diagnostic errors are widely acknowledged as a common patient safety problem, but difficulty in measuring these errors has made it challenging to quantify their impact. This study utilized a large national database of closed malpractice claims to estimate the frequency and severity of diagnostic errors. Researchers also sought to determine the types of diagnoses most vulnerable to misdiagnosis. Missed or delayed diagnoses accounted for 21% of 55,377 claims analyzed, and the majority of these cases resulted in permanent disability or death. These findings corroborate earlier research on closed malpractice claims in primary care and emergency department settings. Investigators found that three groups of diagnoses accounted for the majority of closed claims and high-severity events: vascular events (such as myocardial infarction and stroke), infections (such as sepsis), and cancer. This study represents an important step forward in identifying areas for improvement in diagnosis, but caution should be exercised in extrapolating these results, since malpractice claims only account for a small proportion of all adverse events experienced by patients. A previous PSNet perspective discussed momentum in the field of diagnostic error over the past several years.
Journal Article > Review
Klasen JM, Lingard LA. Med Teach. 2019 Jul 7; [Epub ahead of print].