Narrow Results Clear All
- Patient Safety Primers 1
- WebM&M Cases 3
- Perspectives on Safety 3
- Commentary 19
- Review 2
- Study 13
- Audiovisual 14
- Book/Report 36
- Legislation/Regulation 9
- Newspaper/Magazine Article 87
- Newsletter/Journal 1
- Special or Theme Issue 2
- Toolkit 4
- Web Resource 44
- Award 3
- Clinical Guideline 1
- Grant 2
- Meeting/Conference 2
- Press Release/Announcement 4
- Communication Improvement 59
- Culture of Safety 29
Education and Training
- Students 2
Error Reporting and Analysis
- Error Reporting 46
- Human Factors Engineering 24
Legal and Policy Approaches
- Regulation 19
- Logistical Approaches 8
Quality Improvement Strategies
- Benchmarking 11
- Research Directions 3
- Specialization of Care 10
- Teamwork 7
- Clinical Information Systems 28
- Transparency and Accountability 1
- Alert fatigue 2
- Device-related Complications 16
- Diagnostic Errors 19
- Discontinuities, Gaps, and Hand-Off Problems 17
- Drug shortages 1
- Failure to rescue 2
- Fatigue and Sleep Deprivation 2
- Identification Errors 10
- Medical Complications 17
- Medication Errors/Preventable Adverse Drug Events 28
- MRI safety 1
- Nonsurgical Procedural Complications 4
- Overtreatment 1
- Psychological and Social Complications 13
- Surgical Complications 18
- Allied Health Services 1
- Internal Medicine 32
- Nursing 5
- Palliative Care 1
- Pharmacy 13
- Family Members and Caregivers 20
- Health Care Executives and Administrators 145
Health Care Providers
- Nurses 6
- Physicians 36
Non-Health Care Professionals
- Educators 18
- Media 11
- Australia and New Zealand 9
- Europe 20
- Canada 8
- United States of America 174
Search results for "Health Care Providers"
Weise E. USA Today. May 18, 2005.
Panner M. Forbes. August 12, 2019.
Diagnostic errors can result in harm across the spectrum of practice. Discussing cognitive and system factors in radiology that contribute to diagnostic mistakes, this magazine article recommends ways to reduce risk of errors, including peer review of practice, structured reporting, and artificial intelligence–enabled decision support.
Web Resource > Multi-use Website
8230 Old Courthouse Road, Suite 420, Tysons Corner, VA.
A comprehensive systems-focused approach must be employed in the hospital and at home to ensure reliable medication use. This institute supports multistakeholder activities to enhance policy and education throughout health care to optimize and improve medication practices of caregivers, families, pharmacists, and clinicians.
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.
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.
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.
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 invited Canadian patients, families, clinicians, organization leaders, and policymakers to provide input on the material to ensure its applicability across the country.
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.
Patient Safety Primers
Anyone can find it challenging to understand medical terms, and millions of Americans have trouble understanding and acting upon health information. The mismatch between individuals' health literacy skills and the complexity of health information and health care tasks involved in managing health has implications on patient safety.
Journal Article > Study
Consumers' perspectives on their involvement in recognizing and responding to patient deterioration—developing a model for consumer reporting.
King L, Peacock G, Crotty M, Clark R. Health Expect. 2019;22:385-395.
Gawande A. New Yorker. November 12, 2018.
In this magazine article, Atul Gawande describes a range of frustrations physicians experience as digitization becomes more widespread in health care. He elaborates upon several elements of electronic health record use that can degrade care processes and create conditions for errors, such as burnout, lack of patient-centeredness, and alert fatigue.