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Non-Health Care Professionals
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Search results for "Error Analysis"
- Error Analysis
O'Loughlin E. New York Times. April 30, 2018.
Large-scale adverse events should lead to system examination and improvement. This newspaper article reports on misread cervical cancer tests that resulted in 208 women receiving false negative results over a 4-year period from a publicly funded smear test program in Ireland and the government inquiry launched in response to this large-scale failure.
Youngberg BJ, ed. Jones & Bartlett Learning: Sudbuery MA; 2013. ISBN: 9780763774042.
This revised edition of a comprehensive resource on patient safety includes new chapters discussing such topics as the complexity of defining error and the need for medical and nursing education to develop leadership skills to help drive improvement efforts.
Journal Article > Study
Hinchcliff R, Westbrook J, Greenfield D, Baysari M, Moldovan M, Braithwaite J. Int J Qual Health Care. 2012;24:1-8.
National Patient Safety Agency. London, UK: National Health Service.
These documents summarize National Patient Safety Agency incident reporting data from the first year of data collection. They are accompanied by workbooks for data review, slide sets and trends analysis.
Carruthers I, Phillip P. London, UK: National Patient Safety Agency; 2006.
This report reviews the challenges of patient safety efforts of the National Health Service and provides recommendations to further improve health care safety.
Stout D. New York Times. June 17, 2006;National desk:9.
This article reports on the investigation following the death of New York Times reporter David E. Rosenbaum. The investigation uncovered a range of failures in emergency care and is described in a report available via the link below.
Learning from Bristol: The Report of the Public Inquiry into Children's Heart Surgery at the Bristol Royal Infirmary 1984–1995.
London, England: The Stationery Office; July 2001.
In June 1998, the Secretary for Health announced to Parliament the organization of a formal Inquiry into children's heart surgery at the Bristol Royal Infirmary between 1984 and 1995. Their objectives included understanding what happened in Bristol, assessing the quality of care and system failures that contributed to deaths, and generating lessons that could be learned for the entire National Health Service (NHS) in the United Kingdom. The inquiry was independent and not held as a legal proceeding, but provided a comprehensive investigation with interviews, expert panels, and a goal of driving improvement efforts. Section one of the report outlines pediatric cardiac surgical services in Bristol while section two focuses on recommendations to ensure high quality care across the NHS. Several publications resulted from the learnings of the Bristol inquiry, including a discussion of cultural entrapment and lessons for quality improvement.
van Vuuren W. [dissertation]. Eindhoven, The Netherlands: Eindhoven University of Technology; 1998.
This report provides a detailed review of risk management in complex and high-risk organizations. The author focuses on the analysis and categorization of safety-related incidents and their organizational causes.
Armstrong D. ProPublica. August 23, 2019.
Cullen A. Uitgeverij van Brug: The Hague, The Netherlands; 2019. ISBN: 9789065232236.
Patient stories offer important insights regarding the impact medical errors have on patients and their families. This book shares the author's experience with medical error and spotlights how lack of transparency in European health care can contribute to avoidable process failures that result in patient harm.
O'Rourke M. The Atlantic. September 2019.
Journal Article > Study
Jalal H, Buchanich JM, Roberts MS, Balmert LC, Zhang K, Burke DS. Science. 2018;361:1184.
Opioid overdose deaths remain a threat to patient safety. Information about how overdose deaths are nationally distributed is critical to inform prevention efforts. This robust analysis examined all drug overdose deaths in the United States over a 38-year period. Drug overdoses began increasing exponentially long before the opioid prescribing boom in the mid-1990s and continue to rise in this way. Demographically distinct subepidemics of prescription opioid, synthetic opioid, and stimulant use all contribute to drug overdose deaths as a whole. The authors speculate about what factors other than opioid prescribing might drive escalating substance use-related deaths. An Annual Perspective and a PSNet perspective provide further insights into how safety efforts can reduce opioid-related harm.
Young A, Kelly J, Schnaars C, Ungar L. USA Today.
Daley J. Colorado Public Radio. February 23, 2018.
Innovations in the prescribing of opioids in the emergency department are needed to change practice and help address the opioid crisis. This news article reports the results of a 10-hospital pilot program, the Colorado Opioid Safety Collaborative, which used alternative pain control approaches to reduce opioid prescriptions by an average of 36%. The program builds on multidisciplinary teamwork to modify pain management in the emergency department. An Annual Perspective highlighted opioid misuse as a patient safety challenge.
St. Paul, MN: Minnesota Department of Health; March 2019.
The National Quality Forum has defined 29 never events—patient safety problems that should never occur, such as wrong-site surgery and patient falls. Since 2003, Minnesota hospitals have been required to report such incidents. The 2018 report summarizes information about 384 adverse events that were reported and found pressure ulcers and invasive procedure events increased, while fall-related deaths decreased. Reports from previous years are also available.
Boodman SG. Washington Post. December 9, 2017.
The prevalence of polypharmacy among older patients represents an important concern for health care safety, as unneeded medications can contribute to patient harm. This newspaper article reports on several strategies to reduce inappropriate medication use in older patients, including desprescribing and brown bag medication review.
Journal Article > Study
Ringdal M, Chaboyer W, Ulin K, Bucknall T, Oxelmark L. BMC Nurs. 2017;16:69.
This qualitative study of hospitalized patients in Sweden found that patients expressed interest in engaging in their care. Themes included shared decision-making and increasing patient understanding of health conditions. Patients also expressed concern about the power dynamic between patients and providers and uncertainty about how to best participate in their own hospital care.
William Brangham. PBS News Hour. September 29, 2017.
Hobson K. Health Shots. National Public Radio. September 8, 2017.
Medication regimen nonadherence can result in patient harm. This news article reports the results of a national poll, which found that a substantial number of patients under the age of 35 do not take their medication as directed. Patients who stopped taking medications without consulting their doctors cited various reasons, including forgetfulness, feeling better, and belief the medication did not work .
Mickle K. Glamour Magazine. August 11, 2017.