Search results for "Hospitals"

Maternal mortality is increasing in the United States. This news article reports on this critical safety problem in the context of the preventable death of a patient whose diagnosis of preeclampsia was missed by her providers, despite persistent concerns raised by family about the patient's symptoms.

Patients who have been exposed to medical error could be reluctant to trust the health care system. Providing insights from an epidemiologist's experience with medical errors, in her own care as well as her mother's and her daughter's care, this commentary discusses how physicians can build relationships with patients who have been affected by medical mistakes.

Conflict of interest between health care providers and for-profit industry represents a patient safety concern. This qualitative study examined the relationship between physicians who use implantable devices and the device manufacturer representatives. Although physicians reported being vigilant in their relationship with device representatives and recognized the potential for conflicts of interest, device representatives were often present for implantations.

Nurse fatigue is associated with omissions and errors in care. This qualitative study found that nursing professional culture in its current state poses a challenge to effectively mitigating fatigue among nurses. The authors advocate for future research to develop culture change models and strategies that address these barriers.

Storytelling has been advocated as a strategy to teach and augment awareness in patient safety. In this commentary, the author relates a personal anecdote to illustrate how assumptions can affect clinical reasoning and provides lessons to broaden clinician thinking when working toward determining a diagnosis.

The National Health Service (NHS) has a history of sharing analyses of problems in its system. Summarizing an NHS investigation into the death of a 3-year-old boy, this report highlights the need to improve organizational culture, complaint follow-up, and transparency to reduce opportunities for similar incidents.

Debriefing is an important strategy for learning from defects and for improving performance. It is one of the central learning tools in simulation and is also recommended after a real-life emergency response.

Efforts to improve medication safety in hospital settings often target nurses, such as utilizing barcode medication administration or limiting interruptions during nurses' medication administration tasks. Nurses can also support medication safety by speaking up about medication orders that appear to be incorrect. In this interview study, neonatal intensive care unit nurses were asked to describe scenarios in which they did and did not question medication administration. Investigators found that nurses spoke up about medication administration because of concern for patients and when they felt confident in their medication knowledge. Nurses' work environment could bolster or hinder questioning of medication administration. Interventions to support a positive safety culture and to enhance nurses' medication knowledge could reinforce safe medication administration.

In this piece, a pharmacist highlights the importance of earning patient safety certification.

Nurse leaders play a key role in patient safety. This interview study found that nurse executives advocate for quality and safety with executive boards by building relationships with board colleagues and presenting the rationale for quality and safety practices. The authors conclude the nurse perspectives are critical to providing insights about quality and safety actions to hospital boards.

Health professionals involved in medical errors experience psychological stress, which can have serious consequences if they are unable to cope with their mistake. Reporting on the second victim phenomenon, this news article discusses a well-known incident that led to the suicide of a nurse, how insufficient organizational and peer support systems affect clinicians, initiatives to provide counseling in similar situations, and the need for more universal change.

Uncertainty is often present in various areas of medical practice. This book provides insights regarding uncertainty in treatment and diagnostic processes, the risks associated with overconfidence in medical care, and the complexity around interpreting evidence to determine best practices.

This narrative review found that factors associated with personality, attitudes, role ambiguity, and work environment all contribute to interpersonal conflict in health care settings. The authors describe possible interventions to reduce conflict, which should in turn improve patient safety.

Patients' experiences with safety issues influence their perceptions of hospital quality. This study examined online reviews of hospitals and found concerns discussed in narratives that would not have surfaced using the Hospital Consumer Assessment of Healthcare Providers and Services patient satisfaction instrument. A significant proportion of narrative reviews raised concern about safety and trust.

Stories can be powerful tools for translating experience from frontline medical practice into improvement work. This collection of narratives from various clinicians reveals factors that hinder high reliability in health care practice and contribute to safety hazards and diagnostic errors. Specific situations discussed include lack of peer support, disruptive behavior, and production pressure.

Observation has been used as a way to study opportunities for improvement in teamwork, practice, and guideline compliance. According to this review, observation was utilized most often in high-risk environments—like the emergency department—and helped to identify weaknesses in care processes. The authors also describe drawbacks to this method, such as the Hawthorne effect and the substantial resources required to train observers and data analyzers.

Patient perspectives are critical to inform patient safety efforts. This systematic review identified studies of patient experiences with adverse events. Included studies demonstrate that the types of adverse events patients most often identify are medication errors and suboptimal communication, and that patient demographic characteristics influence the likelihood of reporting these events. Calling for increased use of patient experiences in future studies, the authors suggest that investigations into adverse events are incomplete if patient perspectives are not included. These results demonstrate the ongoing need to enhance patient engagement in safety research. A previous AHRQ WebM&M perspective delves further into engaging patients in safety improvement.

This qualitative study explored the means by which intensive care unit nurses enhance their patients' perception of safety. Nurses emphasized the importance of communicating with patients and families, ensuring patients' physical safety, and building trust with families so that patients feel safe.

Narrative elements of care failures can help motivate commitment to patient safety work by placing the incident in context. Exploring the value of patient perspectives associated with adverse events, this commentary suggests that improvement leaders consider the patient experience when designing harm reduction efforts.

There is a growing concern that lack of emphasis on performing the physical examination will lead to diagnostic errors. This study asked physicians to report cases of oversights in the physical examination which contributed to missed or delayed diagnosis. The majority of incidents reported were errors of omission in which the entire examination was not performed, with smaller proportions reporting misinterpretation or failure to conduct a specific aspect of the examination. Respondents reported delays and failures in diagnosis as well as significant instances of over-treatment and increased cost. This underscores the need to emphasize the importance of the physical examination in medical education and practice as a patient safety strategy. The lead author, Dr. Abraham Verghese, discussed the importance of physical examination in a past AHRQ WebM&M interview.