Narrow Results Clear All

Resource Type
Approach to Improving Safety
Safety Target
Setting of Care
Clinical Area
Target Audience
Error Types
Origin/Sponsor

Search results for "Health Care Executives and Administrators"

1 - 20 of 322 results
  • Health Care Executives and Administrators
  • Patients
Download Selected Citations

Show: 20 | 50 | 100

Audiovisual > Audiovisual Presentation

2015 Rosenthal Symposium: Protecting Patients: Advances and Future Directions in Patient Safety.

National Academy of Medicine. December 10, 2015; National Academy of Sciences Building, Washington, DC.

In recognition of the 15th anniversaries since To Err Is Human and Crossing the Quality Chasm were published, this symposium discussed accomplishments and persisting challenges in the fields of patient safety and quality improvement since those reports were released. The session featured Dr. Donald Berwick, Dr. Lucian Leape, and Carolyn Clancy as speakers.

Audiovisual

Avoiding medical error.

Colvin G. "The Colvin Interview." CNN. February 5, 2007.

This video segment features an interview with two McKesson executives about how health information technology can help prevent medication errors.

Newspaper/Magazine Article

Medical error led to death of patient, 77.

Gledhill V. The Evening Chronicle. January 25, 2007;News section:9.

This article reports on a patient death caused by medical omission and the communication failures that occurred with both the family and regulatory body after the incident.

Newspaper/Magazine Article

Settlement to be used for hospital training in labeling medicines.

Ostrom CM. Seattle Times. September 13, 2005;Local News:B3 

This article reports on how one family and hospital will use personal tragedy to create awareness in practitioners of the importance of accurate labeling in hospitals.

Newspaper/Magazine Article

Hospital takes a page from Toyota.

Connolly C. MSNBC News. June 3, 2005.

This article reports on one hospital's adoption of Japanese business philosophy to improve its cancer center. The approach, adapted from Toyota Motor Corporation, is focused on high quality, efficiency, and customer-centeredness.

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...

Newspaper/Magazine Article

Medical residents angered at extended work hours.

Hurt J. Med Econ. April 26, 2017.

Discussions about resident work hours generate debate regarding safety and physician burnout. This magazine article reports resident physician concerns about the shift hour changes that allow for flexible duty hours within a maximum 80-hour workweek.

Book/Report

Adverse Health Events in Minnesota: 13th Annual Public Report.

St. Paul, MN: Minnesota Department of Health; February 2017.

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 2016 report summarizes information about 336 adverse events that were reported and found that while deaths due to medical error rose, the number of falls and fall-related deaths reached the lowest point since 2011. There were no reported incidence of patient suicide for the first time since 2011. Reports from previous years are also available.

Book/Report

Partnership for Patients (PfP) Hospital Engagement Network (HEN) 2.0 Final Report.

Chicago, IL: American Hospital Association and Health Research & Educational Trust; September 2016.

The Partnership for Patients program has supported the Hospital Engagement Networks since 2011. This report reviews the results of the second round of funded effort, which involved more than 1500 hospitals in the United States that prevented 34,000 harms from September 2015 to September 2016. Areas of improvement included reductions in surgical site infections, adverse drug events, and postoperative complications. The authors also highlight core strategies of the program, such as evidence dissemination and coaching.

Book/Report

Bipartisan Consensus: The Public Wants Well-Rested Medical Residents to Help Ensure Safe Patient Care.

Almashat S, Carome M, Wolfe S, Landrigan CP, Czeisler C. Washington, DC: Public Citizen; September 13, 2016.

Duty-hour limitations have been implemented as a strategy to address resident fatigue, but they remain controversial. This report summarizes the results of a national poll that sought to assess public opinion regarding removing 16-hour shift restrictions and transparency around clinician work time.

Journal Article > Commentary

Patient and family empowerment as agents of ambulatory care safety and quality.

Roter DL, Wolff J, Wu A, Hannawa AF. BMJ Qual Saf. 2017;26:508-512.

Effective team communication is a key component of safe care. This commentary discusses the role of patient–family partnerships in enhancing health care safety in ambulatory and home settings. The authors describe a communication intervention to improve patient and family collaboration during ambulatory care visits. Components of the approach included engaging family participation in routine visits and coaching them to ask questions.

Web Resource > Multi-use Website

Indiana Patient Safety Center.

Indiana Hospital Association.

Launched in 2006, the Indiana Patient Safety Center (IPSC) is dedicated to promoting safety culture and reliable systems of care in the state. This website provides resources related to IPSC educational activities and efforts to raise awareness of local and national safety initiatives, including the Hospital Engagement Network.

Newspaper/Magazine Article

Many well-known hospitals fail to score high in Medicare rankings.

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.

Journal Article > Study

Patients and families as teachers: a mixed methods assessment of a collaborative learning model for medical error disclosure and prevention.

Langer T, Martinez W, Browning DM, Varrin P, Sarnoff Lee B, Bell SK. BMJ Qual Saf. 2016;25:615-625.

Health systems struggle with how to effectively involve patients in safety efforts without placing undue responsibility or blame on them. Greater patient–clinician collaboration is particularly important for error disclosure because of the well-documented gaps in clinician and patient perspectives. In this study, investigators developed an intervention to have patients or family members teach error disclosure and prevention to interprofessional clinician learners, including physicians, nurses, and social workers. Their pre–post evaluation showed that the majority of patient and clinician participants reported improved communication and found the intervention valuable. Patient and clinician participation was voluntary. Although these results show promise for involving patients and families as teachers for error disclosure and prevention training, further work is needed to determine whether this approach will be effective among broader health care teams, as opposed to interested clinicians who volunteer. A related editorial discusses the challenges of including patients in safety efforts.

Newspaper/Magazine Article

Pathologists, patients and diagnostic errors—part 1 and part 2.

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.

Newspaper/Magazine Article

Mean girls of the ER: the alarming nurse culture of bullying and hazing.

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.

Newspaper/Magazine Article

Nurses say stress interferes with caring for their patients.

Yu A. Health Shots. National Public Radio. April 15, 2016.

Many health care professionals exhibit symptoms of burnout, which may impair their ability to maintain safe practices and detect potential errors. This news article explores organizational factors that contribute to nurse burnout, including low staffing and increased workloads due to electronic health record implementation.

Newspaper/Magazine Article

Reducing preventable harm in hospitals.

Bornstein D. New York Times. January 26, and February 2, 2016.

Discussing the importance of designing safeguards to prevent system failures that can result in patient harm, this two-part newspaper article reviews large-scale collaboratives, including the Partnership for Patients initiative, as approaches that show promise in engaging clinicians in safety improvement and explores specific areas of focus to reduce harm such as hospital-acquired infections, patient falls, and culture change.

Newspaper/Magazine Article

At the hospital, better responses to those beeping alarms.

Landro L. Wall Street Journal. January 4, 2016.

Alert fatigue is a well-known problem in hospitals. This newspaper article reports on efforts to reduce unnecessary alarms in hospitals to prevent staff from overlooking critical alerts. Highlighting strategies such as using secondary notification systems and recalibrating alerts according to the severity of physiologic change, the article also describes organizational guidelines to improve alarm safety. A recent WebM&M commentary explored how alarm fatigue can result in patient harm.

Newspaper/Magazine Article

The most crucial half-hour at a hospital: the shift change.

Landro L. Wall Street Journal. October. 26, 2015.

Information exchange can be challenging when nurses hand off care responsibilities at the end of their shifts. This news article discusses bedside shift reports as a strategy to improve communication among nursing staff and engage patients in their care.

Back to Top