Narrow Results Clear All
- Patient Safety Primers 1
- WebM&M Cases 3
- Perspectives on Safety 4
- Commentary 21
- Review 2
- Study 23
- Slideset 1
- Book/Report 49
- Legislation/Regulation 10
- Newspaper/Magazine Article 128
- Newsletter/Journal 1
- Special or Theme Issue 3
- Toolkit 6
- Web Resource 53
- Award 4
- Clinical Guideline 1
- Grant 3
- Meeting/Conference 2
- Press Release/Announcement 5
- Communication Improvement 72
- Culture of Safety 37
Education and Training
- Students 5
Error Reporting and Analysis
- Error Reporting 68
- Human Factors Engineering 30
Legal and Policy Approaches
- Regulation 32
- Logistical Approaches 10
Quality Improvement Strategies
- Benchmarking 13
- Research Directions 3
- Specialization of Care 9
- Teamwork 9
- Clinical Information Systems 36
- Transparency and Accountability 3
- Alert fatigue 2
- Device-related Complications 20
- Diagnostic Errors 23
- Discontinuities, Gaps, and Hand-Off Problems 19
- Drug shortages 2
- Failure to rescue 1
- Fatigue and Sleep Deprivation 4
- Identification Errors 11
- Medical Complications 26
- Medication Errors/Preventable Adverse Drug Events 33
- MRI safety 1
- Nonsurgical Procedural Complications 4
- Overtreatment 1
- Psychological and Social Complications 21
- Surgical Complications 27
- Transfusion Complications 1
- Ambulatory Care 22
- General Hospitals 25
- Long-Term Care 2
- Outpatient Surgery 4
- Patient Transport 1
- Psychiatric Facilities 2
- Allied Health Services 1
- Internal Medicine 54
- Pediatrics 18
- Nursing 5
- Palliative Care 1
- Pharmacy 12
- Family Members and Caregivers 26
- Health Care Executives and Administrators 187
Health Care Providers
- Nurses 6
- Physicians 35
Non-Health Care Professionals
- Educators 25
- Engineers 12
- Media 20
- Policy Makers 110
- Australia and New Zealand 10
- Europe 27
- Canada 8
- United States of America 243
Search results for "Non-Health Care Professionals"
- Non-Health Care Professionals
Geneva, Switzerland: World Health Organization; 2019.
Reducing adverse medication events is a worldwide challenge. This collection of technical reports explores key areas of concern that require action at a system level to improve: high-alert medications, polypharmacy, and medication use at care transitions. Each monograph provides an overview of the topic as well as practical improvement approaches for patients, clinicians, and organizations.
Web Resource > Multi-use Website
Farnborough, Hampshire, UK.
Independent investigations examine system weaknesses in health care to inform improvement, reduce risk, and prevent harm. This organization collects information from individuals, groups, and organizations to identify and analyze incidents of substandard care and to proactively provide recommendations to reduce conditions that perpetuate failure in the National Health Service. Investigation areas include medication delivery for older patients and safe maternity care.
Web Resource > Multi-use Website
American Hospital Association.
Maternal harm is a patient safety concern that is increasingly prioritized in regulatory and care delivery environments. This website provides tools, policies, news articles, case studies, and information for patients and families to inform efforts to protect mothers and infants across geographic regions.
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.
CDC Vital Signs. May 7, 2019.
Maternal morbidity and mortality is a worldwide patient safety problem. This analysis describes the prevalence of pregnancy-related death and areas of concern during pregnancy, at delivery, and up to a year postpartum. It reports that 60% of these deaths are preventable and provides suggestions for families, clinicians, and systems to reduce risks.
Legislation/Regulation > Colorado Legislation
Pettersen B, Tate J, Tipper K, McKean H. Colorado Senate Bill 19-201.
Communication-and-resolution mechanisms are seen as important approaches to improving transparency and healing after an adverse event. This state bill, referred to as the "Colorado Candor Act," protects conversations between organizations, clinicians, patient, and families from legal discoverability and outlines criteria to guarantee that protection.
Jewett C. Kaiser Health News. May 3, 2019.
Transparency has been heralded as a cornerstone to improvement in health care. This news article reports on a government alternative summary reporting program that allowed medical device makers to conceal safety events and malfunction reports associated with medical devices. A new program that expands access to information about device-related failures will be put in place.
Journal Article > Study
Shen C, Nguyen M, Gregor A, Isaza G, Beattie A. JAMA Ophthalmol. 2019;137:690-692.
This study entered 42 validated clinical vignettes for eye diseases into an online symptom checker. As with prior studies, the performance of the online symptom checker in producing the correct diagnosis was suboptimal. The authors suggest that current performance of symptom checkers is not sufficient for timely and accurate diagnosis of ophthalmologic conditions.
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.
Canadian Patient Safety Institute and Health Standards Organization.
This draft 5-year framework aims to guide the activities in Canada to focus action, resources, and policy development on supporting care improvement. The document is structured around five goals: people-centered care, safe care, accessible care, appropriate care, and continuous care. The authors call for Canadian patients, families, clinicians, organization leaders, and policymakers to provide input on the material to ensure its applicability across the country. The deadline for submitting comments is June 30, 2019.
Schulte F, Fry E. Kaiser Health News, Fortune Magazine. March 18, 2019.
Despite years of investment and government support, electronic health records (EHR) continue to face challenges as a patient safety strategy. This news article outlines the unintended consequences of EHR implementation, including patient harm linked to software glitches and user errors, fraudulent behavior (upcoding), interoperability problems, clinician burnout due to poorly designed digital health records, and lack of industry transparency.
Topol E. New York, NY: Basic Books; 2019. ISBN: 978-1541644632.
This book explores how advancements in technology can improve decision making but may also diminish patient-centered care. The author discusses the potential of big data, artificial intelligence, and machine learning to enhance diagnosis and care delivery. A past PSNet interview with the author, Eric Topol, talked about the role of patients in the new world of digital health care.
Dickson EJ. Rolling Stone. March 9, 2019.
Unintended consequences of restrictions enacted to combat the opioid crisis are a concern for patients and prescribers. This magazine article reports on an effort to raise awareness of the potential for patient harm due to lack of legitimate access to opioids for chronic pain as a result of the 2016 CDC opioid prescribing guidelines.
US Food and Drug Administration. March 8, 2019.
Errors of commission during complex procedures can contribute to patient harm. Drawing from an analysis of medical device reports submitted to the Food and Drug Administration, this announcement seeks to raise awareness of common adverse events associated with surgical staplers and implantable staples. User-related problems include opening of the staple line, misapplied staples, and staple gun difficulties. Recommendations include ensuring availability of various staple sizes and avoiding use of staples on large blood vessels.
Rau J. Kaiser Health News. March 1, 2019.
Financial incentives may encourage adoption of practice improvements that enhance safety. This news article reports on the increase in United States hospitals that have had Medicare payments withheld due to high rates of hospital-acquired conditions. The article is accompanied by a state-level tally of individual hospitals penalized.
Chisholm P. Health Shots. National Public Radio. February 27, 2019.
Patient Safety Primers
Anyone can find it challenging to understand medical terms, and millions of Americans have trouble understanding and acting upon health information. The mismatch between individuals' health literacy skills and the complexity of health information and health care tasks involved in managing health has implications on patient safety.
Mohr H, Weiss M. Associated Press. November 27, 2018.
Gawande A. New Yorker. November 12, 2018.
In this magazine article, Atul Gawande describes a range of frustrations physicians experience as digitization becomes more widespread in health care. He elaborates upon several elements of electronic health record use that can degrade care processes and create conditions for errors, such as burnout, lack of patient-centeredness, and alert fatigue.
Web Resource > Multi-use Website
Australian National Health and Medical Research Council.
Overdiagnosis and the subsequent overuse of medical care contributes to unnecessary financial, psychological, and physical risk to patients. This research collaborative draws from expertise and experience from organizations in Australia investigating the problem of overdiagnosis and testing solutions to prevent medical care overuse.