Narrow Results Clear All
- Communication Improvement 3
- Culture of Safety 4
- Education and Training 2
- Error Reporting and Analysis 8
- Human Factors Engineering 1
- Legal and Policy Approaches
- Logistical Approaches 1
- Quality Improvement Strategies 4
- Transparency and Accountability 1
- Device-related Complications 1
- Diagnostic Errors 2
- Discontinuities, Gaps, and Hand-Off Problems 2
- Medication Safety 2
- Psychological and Social Complications 2
- Surgical Complications 1
- Family Members and Caregivers 1
- Health Care Executives and Administrators
Health Care Providers
- Nurses 2
Non-Health Care Professionals
- Media 4
Search results for "Patients"
Hixenbaugh M, Ornstein C. Houston Chronicle and Propublica.
This news investigation chronicles a series of incidents in a transplant program that resulted in patient harm. The systemic nature of the problems such as insufficient whistleblower protection, accountability, and follow-up on patient concerns culminated in a change of hospital leadership. A previous PSNet interview with Charles Ornstein discussed the role of media in raising awareness of patient safety issues.
Rau J. National Public Radio. July 27, 2016.
Although quality rating systems have yet to receive approval across the health care industry, they still serve as a way for consumers to select hospitals and providers. The developers of rating services continue to refine metrics to hone their effectiveness. This news article reports on the latest set of ratings from the Hospital Compare program and concerns associated with the results.
Miller N. The Pathologist. June 2016(20):18-29; July 2016(21):18-33.
In light of the growing focus on diagnostic errors, this magazine series reports on unique challenges that pathologists face when they discover potential errors. The first article in the series discusses how pathologists may experience barriers to disclosure including feeling shame in disclosing their own error, discomfort with raising concerns about a colleague who has misdiagnosed a patient, and lack of direct relationships with patients. The second article expands the discussion to focus on how industry support of open transparency can enable pathologists to participate in reporting and disclosure activities.
Robbins A. Good Housekeeping. May 20, 2016.
Disruptive behaviors are receiving increased attention as a cultural factor that contributes to medical error. Although much of the focus has been on physicians, the presence of bullying among nurses is also a concern. This magazine article explores nurse behaviors such as withholding information, intimidation, and name calling that negatively affect patient safety and nurse retention.
Parikh R. The Atlantic. August 18, 2014.
The inappropriate use of physical restraints on patients is considered a sentinel event. Although restraints may be used to protect patients from harm, this magazine article highlights risks related to their use—such as increased rates of pressure ulcers and delirium—and advocates for a more patient-sensitive approach to ensure the safety of both patients and caregivers.
Clark C. HealthLeaders Media. August 7, 2014.
Although California has collected an estimated $15 million in penalties from hospitals for adverse events, this news piece describes how much of the money has yet to be allocated or spent on safety improvement projects. Moreover, some state agencies have been reluctant to provide specific data to projects that have already been funded.
Clark C. HealthLeaders Media. September 13, 2013.
This news piece highlights concern around the safety of elective premature deliveries and describes techniques organizations have used to prevent such procedures.
Jain M. Washington Post. May 27, 2013.
Brown T. New York Times. March 17, 2013:SR5.
Dwyer J. New York Times. July 11, 2012:A15.
This newspaper article reports on gaps in communication and a missed sepsis diagnosis that led to a patient's death.
Journal Article > Study
High-profile investigations into hospital safety problems in England did not prompt patients to switch providers.
Laverty AA, Smith PC, Pape UJ, Mears A, Wachter RM, Millett C. Health Aff (Millwood). 2012;31:593-601.
While medical errors continue to affect patients on a daily basis, most organizations fear high-profile cases that land on front pages of newspapers or lead to extensive regulatory intervention. This study evaluated the role of England's Care Quality Commission in their own regulatory investigation of major issues occurring in three hospitals. The investigations led to considerable media attention, but whether this influenced patient behavior was unknown. The authors found that the investigations had zero impact on utilization at two of the hospitals. The third experienced a decrease in inpatient admissions and new patient visits, but the effect dissipated 6 months following the public report. In an era of greater transparency and increased attention on patient safety, these findings suggest that patients' decision-making is perhaps less influenced than expected by such events. Two past AHRQ WebM&M perspectives discussed organizational change in the face of highly public errors at Duke and the Dana Farber Cancer Institute.
Journal Article > Study
Hinchcliff R, Westbrook J, Greenfield D, Baysari M, Moldovan M, Braithwaite J. Int J Qual Health Care. 2012;24:1-8.
Perspectives on Safety > Interview
The Patient's Role in Safety, March 2007
Sorrel King is the mother of Josie King, who died tragically in 2001 at age 18 months because of medical errors during a hospitalization at Johns Hopkins Hospital. She has subsequently become one of the nation’s foremost patient advocates for safety, forming an influential foundation (the Josie King Foundation) and partnering with Johns Hopkins to promote the field of patient safety around the world.
Four Corners. ABC Television. July 3, 2006.
This Web site on an Australian documentary provides links to resources and an online forum discussing patient safety.
Scathing report on Kaiser kidney program. Transplant delays assailed -- Medicare threatens to end coverage.
Russell S. San Francisco Chronicle. June 24, 2006.
This article reports on a Centers for Medicare & Medicaid Services report that details deficiencies in Kaiser's kidney transplant program.
Journal Article > Study
Stebbing C, Kaushal R, Bates DW. Pediatrics. 2006;117:1907-1914.
This study analyzed newspaper coverage of pediatric medication errors and adverse drug events in five countries to demonstrate increased interest in the topic over the past decade. Investigators examined the number of articles and the types of events covered and assessed the overall themes presented and framed by the media. The majority of articles published covered patient incidents followed by policy and then research in decreasing order of frequency. Despite the occasional occurrence of sensational reporting on errors, more than 70% of articles that were deemed to be negatively associated with patient safety were covered in a neutral manner.
Wolosin R, Vercler L, Matthews J. Patient Safety & Quality Healthcare. November/December 2005;2:40-44.
The authors examined patients' perceptions of safety in hospital settings and factors that affect their perceptions.
Perspectives on Safety > Perspective
Organizational Change in the Face of Highly Public Errors—I. The Dana-Farber Cancer Institute Experience
with commentary by James B. Conway; Saul N. Weingart, MD, PhD, Errors in the Media and Organizational Change, May 2005
A decade ago, two tragic medical errors rocked one of the world’s great cancer hospitals, Dana-Farber Cancer Institute (DFCI) in Boston, to its core. The errors led to considerable soul searching and, ultimately, a major change in institutional practices a...