Narrow Results Clear All
- Patient Safety Primers 1
- WebM&M Cases 8
- Perspectives on Safety 5
- Commentary 42
- Review 6
- Study 54
- Slideset 1
- Book/Report 72
- Legislation/Regulation 11
- Newspaper/Magazine Article 188
- Newsletter/Journal 2
- Special or Theme Issue 5
- Toolkit 11
- Forum 1
- Award 4
- Clinical Guideline 1
- Grant 2
- Meeting/Conference 6
- Press Release/Announcement 29
Communication between Providers
- Sbar 1
- Communication between Providers 30
- Culture of Safety 49
Education and Training
- Students 2
Error Reporting and Analysis
- Error Reporting 107
Human Factors Engineering
- Checklists 13
Legal and Policy Approaches
- Regulation 23
- Logistical Approaches 15
- Policies and Operations 4
Quality Improvement Strategies
- Benchmarking 15
- Research Directions 5
- Specialization of Care 15
- Teamwork 13
- Clinical Information Systems 35
- Transparency and Accountability 6
- Alert fatigue 2
- Device-related Complications 27
- Diagnostic Errors 42
- Discontinuities, Gaps, and Hand-Off Problems 37
- Drug shortages 1
- Failure to rescue 2
- Fatigue and Sleep Deprivation 4
- Identification Errors 22
- Interruptions and distractions 2
- Delirium 1
- Medication Errors/Preventable Adverse Drug Events 81
- MRI safety 1
- Nonsurgical Procedural Complications 8
- Overtreatment 4
- Psychological and Social Complications 39
- Surgical Complications 46
- Transfusion Complications 1
- Home Care 10
- General Hospitals 69
- Long-Term Care 7
- Outpatient Surgery 5
- Patient Transport 1
- Psychiatric Facilities 1
- Allied Health Services 1
- Internal Medicine 84
- Obstetrics 11
- Pediatrics 33
- Primary Care 13
- Nursing 17
- Palliative Care 2
- Pharmacy 61
- Family Members and Caregivers 52
- Health Care Executives and Administrators 271
Health Care Providers
- Nurses 35
- Pharmacists 28
- Physicians 111
Non-Health Care Professionals
- Educators 16
- Media 11
- Australia and New Zealand 10
- Europe 42
- Canada 20
United States of America
United States Federal Government
- Department of Health and Human Services (HHS) 58
- United States Federal Government 64
Search results for "Health Care Providers"
- Health Care Providers
Weise E. USA Today. May 18, 2005.
Appleby J, Lucas E. Kaiser Health News. June 21, 2019.
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.
Journal Article > Study
DesRoches CM, Bell SK, Dong Z, et al. Ann Intern Med. 2019 May 28; [Epub ahead of print].
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.
Palmer J. Patient Saf Qual Healthc. May/June 2019.
Organizations must learn from adverse events to prevent similar incidents. Reporting on lessons to be learned from the cascade of failures connected with the preventable death of a patient during an acute asthma attack at the door of a hospital emergency department, this magazine article outlines the importance of effective signage, appropriate security staff placement, and acceptance of the responsibility for failure.
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.
FDA identifies harm reported from sudden discontinuation of opioid pain medicines and requires label changes to guide prescribers on gradual, individualized tapering.
Silver Spring, MD: US Food and Drug Administration; April 9, 2019.
Efforts to address the opioid epidemic range from regulation to changes in pain management. This safety announcement raises awareness of potential harms associated with rapidly decreasing the dose of or discontinuing opioids for patients who may be physically dependent on the medication. It also announces a requirement regarding changes to prescribing information for opioids to provide expanded guidance on how to safely taper doses. Health care providers should discuss tapering plans with patients and provide ongoing monitoring and support.
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.
Cullen A. Uitgeverij van Brug: The Hague, The Netherlands; 2019. ISBN: 9789065232236.
Patient stories offer important insights regarding the impact medical errors have on patients and their families. This book shares the author's experience with medical error and spotlights how lack of transparency in European health care can contribute to avoidable process failures that result in patient harm.
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.
Chisholm P. Health Shots. National Public Radio. February 27, 2019.