Narrow Results Clear All
Communication between Providers
- Sbar 4
- Communication between Providers 142
- Culture of Safety 106
Education and Training
- Simulators 16
- Students 9
Error Reporting and Analysis
- Never Events 11
- Error Reporting 174
Human Factors Engineering
- Checklists 41
Legal and Policy Approaches
- Regulation 53
- Logistical Approaches 67
Quality Improvement Strategies
- Benchmarking 15
- Specialization of Care 43
- Teamwork 50
- Clinical Information Systems 104
- Alert fatigue 1
- Device-related Complications 67
- Diagnostic Errors 85
- Discontinuities, Gaps, and Hand-Off Problems 89
- Drug shortages 16
- Fatigue and Sleep Deprivation 21
- Identification Errors 44
- Interruptions and distractions 10
- Delirium 1
- Medication Errors/Preventable Adverse Drug Events 243
- MRI safety 4
- Nonsurgical Procedural Complications 20
- Psychological and Social Complications 67
- Second victims 3
- Surgical Complications 133
- Transfusion Complications 4
- Ambulatory Care 90
- General Hospitals 181
- Long-Term Care 13
- Outpatient Surgery 18
- Patient Transport 7
- Psychiatric Facilities 5
- Allied Health Services 2
- Dentistry 2
- Geriatrics 14
- Obstetrics 17
- Pediatrics 44
- Primary Care 10
- Radiology 16
- Internal Medicine 275
- Nursing 60
- Pharmacy 181
- Family Members and Caregivers 20
- Health Care Executives and Administrators 560
Health Care Providers
- Nurses 91
- Pharmacists 83
- Physicians 160
Non-Health Care Professionals
- Educators 34
- Engineers 38
- Media 9
- Patients 494
- Asia 1
- Europe 37
- Canada 12
United States of America
United States Federal Government
- Department of Health and Human Services (HHS) 10
- United States Federal Government 13
Search results for ""
Day passes for vulnerable patients of psychiatric hospitals can have dangerous, even fatal consequences.
Woodruff E. Baltimore Sun. June 9, 2017.
Landi H. Healthcare Informatics. June 1, 2017.
The use of copy and paste is a popular time-saving mechanism to update electronic medical documentation, but this practice can introduce risks. This news article reports on various resources that explore problems associated with the copying and pasting in electronic health records, including a recent study that highlighted how this practice can perpetuate incomplete or wrong information into patient records.
ISMP Medication Safety Alert! Acute Care Edition. May 18, 2017;22:1-4.
Verbal orders are known to increase risk of error in care. This newsletter article summarizes survey results that sought to characterize current verbal order behaviors. Notably, practices to improve the reliability of verbal orders such as read backs were not optimally integrated in medication processes. The article includes recommendations for organizations, individuals, and teams to improve the safety of verbal orders.
Martin N, Montagne R. ProPublica and National Public Radio. May 12, 2017.
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.
Jewett C. Kaiser Health News. May 9, 2017.
The Centers for Medicare and Medicaid Services decision to withhold payment for certain hospital-acquired conditions has prompted widespread efforts to prevent such events. This news article reports on an evaluation by the Office of Inspector General that found regulator review of hospital-acquired infection reports submitted to Medicare to be insufficient, which hinders hospitals' ability to learn from factors that contribute to infections.
Brouillette M. MIT Technol Rev. April 27, 2017.
Hurt J. Med Econ. April 26, 2017.
Ornstein C. Health Shots. National Public Radio and ProPublica. April 18, 2017.
Summary data about serious errors in hospitals are available, but often details of accreditation investigation findings are not accessible to the public. This news article reports on efforts by the Centers for Medicare and Medicaid Services to make this information publicly available to augment transparency and enhance health care safety.
Carr S. ImproveDx. April 2017;4:1-4.
Headley M. Patient Saf Qual Healthc. April 5, 2017.
Couch C. Fast Company. April 3, 2017.
Two effective initiatives for C-suite leaders to improve medication safety and the reliability of outcomes.
ISMP Medication Safety Alert! Acute Care Edition. March 23, 2017;22:1-5.
Boodman SG. Kaiser Health News. March 15, 2017.
This news article reports on two incidents involving medical errors—one demonstrating the traditional shroud of secrecy and the other building on transparency and open disclosure—to illustrate the value of honest apology, discussion, and resolution of medical error for clinicians, patients, and families.
Lawes S, Grissinger M. PA-PSRS Patient Saf Advis. March 2017;14:1-8.
The unintended consequences associated with health information technologies for medication management are well documented. Drawing from 889 medication error reports submitted over a 6-month period, this analysis found that more than half of the recorded incidents were associated with computerized provider order entry. Staff reporting of medication errors and near misses is key to identifying trends and consequently developing system improvements to reduce risks of such incidents.
Clements K. Nurs Manage. 2017;48:12-13.
Khullar D. New York Times. February 22, 2017.
Implementing design changes in care environments can improve patient safety. This newspaper article reports on how efforts to address hospital design concerns can augment infection control, patient-centeredness, fall prevention, and noise reduction. A past PSNet perspective discussed physical space redesign as a patient safety strategy.
Hofmann PB, Bagian JP. Patient Saf Qual Healthc. February 20, 2017.
Baker M. Seattle Times. February 10, 2017.
Reporting on an incident involving a patient who died after a surgery, this news article discusses potential contributing factors in the incident such as concurrent surgeries and failure to consider patient and family concerns. A past WebM&M commentary highlighted the importance of listening to families when they advocate for patients in the hospital.
Lewis M. Nautilus. February 9, 2017.
Physicians' decision-making can be diminished when they are tired, distracted, or too narrowly task-focused. This article discusses cognitive biases and other limitations that affect physicians' ability to process information effectively and explores how these factors can contribute to uncertainty and clinical misjudgment.
ISMP Medication Safety Alert! Acute Care Edition. February 9, 2017;22:1-5.
Monitoring external reports of error and harm can prompt organizations and clinicians to look for similar risks in their own health care systems. This newsletter article reviews attribution biases that hinder improvement and discusses recommendations to address them, including leadership commitment to learning and infrastructure processes to track published information.