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- Communication Improvement 1
- Culture of Safety 1
- Education and Training 2
- Error Reporting and Analysis 3
- Human Factors Engineering 1
- Legal and Policy Approaches 1
- Logistical Approaches 1
- Quality Improvement Strategies 1
- Technologic Approaches 1
- Device-related Complications 1
- Diagnostic Errors 2
- Discontinuities, Gaps, and Hand-Off Problems 1
- Medical Complications 1
- Medication Safety 3
- Surgical Complications
- Pharmacy 1
Search results for "Internal Medicine"
Journal Article > Commentary
Graber ML, Berg D, Jerde W, Kibort P, Olson APJ, Parkash V. Diagnosis (Berl). 2018;5:257-266.
This commentary provides a clinical review of a missed diagnosis of Epstein-Barr virus infection that was identified via autopsy and summarizes contributing factors to the incident with an emphasis on the role of cognitive bias. The piece includes the perspectives of the patient's family and from the organization regarding what happened and what could have been done to prevent this outcome. This discussion is the first in a series of diagnostic error case presentations to be published in this journal.
Journal Article > Study
Application of the aviation black box principle in pediatric cardiac surgery: tracking all failures in the pediatric cardiac operating room.
Bowermaster R, Miller M, Ashcraft T, et al. J Am Coll Surg. 2015;220:149–155.e3.
This observational study describes how a pediatric cardiac surgery team used the human factors approach of recording even small deviations from ideal practice in order to better characterize safety problems. The authors describe how systematically capturing small failures led to recognition of faulty processes that could be addressed. A recent AHRQ WebM&M commentary discusses the application of human factors engineering to enhance safety of medical device design.
Journal Article > Study
Avansino J, Leu MG. Pediatrics. 2012;130:e547-e552.
Web Resource > Multi-use Website
Ohio Business Roundtable. 41 S. High Street, Suite 2240, Columbus, OH, 43215.
Grant > Government Resource
AHRQ Risk-informed Intervention Development and Implementation of Safe Practices in Ambulatory Care.
Rockville, MD: Agency for Healthcare Research and Quality; October 2008.
This AHRQ grantee announcement lists 13 projects funded to demonstrate effective strategies in identifying and addressing risks and in improving processes in ambulatory care.