Narrow Results Clear All
Communication between Providers
- Sbar 4
- Communication between Providers 143
- Culture of Safety 106
Education and Training
- Simulators 16
- Students 9
Error Reporting and Analysis
- Never Events 11
- Error Reporting 175
Human Factors Engineering
- Checklists 41
Legal and Policy Approaches
- Regulation 54
- Logistical Approaches 67
Quality Improvement Strategies
- Benchmarking 15
- Specialization of Care 43
- Teamwork 50
- Clinical Information Systems 105
- Alert fatigue 1
- Device-related Complications 67
- Diagnostic Errors 87
- Discontinuities, Gaps, and Hand-Off Problems 90
- Drug shortages 16
- Fatigue and Sleep Deprivation 21
- Identification Errors 44
- Interruptions and distractions 10
- Delirium 1
- Medication Errors/Preventable Adverse Drug Events 245
- MRI safety 4
- Nonsurgical Procedural Complications 20
- Psychological and Social Complications 69
- Second victims 3
- Surgical Complications 134
- Transfusion Complications 4
- Ambulatory Care 93
- General Hospitals 183
- Long-Term Care 14
- Outpatient Surgery 18
- Patient Transport 7
- Psychiatric Facilities 5
- Allied Health Services 2
- Dentistry 2
- Geriatrics 15
- Obstetrics 18
- Pediatrics 44
- Primary Care 10
- Radiology 16
- Internal Medicine 277
- Nursing 60
- Pharmacy 183
- Family Members and Caregivers 20
- Health Care Executives and Administrators 563
Health Care Providers
- Nurses 91
- Pharmacists 85
- Physicians 160
Non-Health Care Professionals
- Educators 34
- Engineers 38
- Media 9
- Patients 496
- 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 ""
Kowalczyk L. Boston Globe. July 29, 2017.
Maron DF. Sci Am. July 21, 2017.
Abbasi J. JAMA. 2017;318:506-508.
Boodman SG. Kaiser Health News. July 12, 2017.
Rau J. Kaiser Health News. July 6, 2017.
System failures contribute to recurring problems in health care environments. This news article spotlights how lack of follow-up or action related to inspection reports that have uncovered factors in long-term care facilities that contribute to inadequate care can enable poorly performing nursing homes to remain in operation.
ISMP Medication Safety Alert! Acute Care Edition. June 29, 2017;16:1-5.
Adopting new technologies in health care can have unintended consequences that diminish patient safety. This newsletter article explores the impact of texting in health care, reviews both improvements and problems associated with the practice, and notes limited understanding regarding their occurrence. A past WebM&M commentary discussed problems stemming from an interruption caused by texting.
ISMP Medication Safety Alert! Acute Care Edition. June 15, 2017;22:1-4.
Compounding pharmacies prepare medicines for patients that aren't available as commercial products. Reviewing a case involving a pediatric patient who died after receiving a compounded oral liquid suspension that contained the wrong medication, this newsletter article discusses weaknesses in compounding processes that contributed to the incident. Recommendations for pharmacies to reduce opportunities for error include independent double-checks and designated areas for compounding activities.
Thew J. HealthLeaders Media. June 14, 2017.
Day passes for vulnerable patients of psychiatric hospitals can have dangerous, even fatal consequences.
Woodruff E. Baltimore Sun. June 9, 2017.
Deutsch ES. PA-PSRS Patient Saf Advis. June 2017;14:80-83.
Understanding what is possible in the context of frontline practice is key when designing enhancements to augment care safety. Discussing the difference between work-as-imagined and work-as-done, this commentary highlights the value of combining the two approaches to inform and implement improvements in health care.
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.
Straka M, Gaunt MJ, Grissinger M. PA-PSRS Patient Saf Advis. 2017;14:55-63.
According to this analysis of more than 1000 reports of errors occurring in community pharmacies, more than half reached the patient. Common error types included wrong drug and wrong dose incidents. Counseling patients on their medications at the point of sale can improve the reliability of outpatient pharmacy practice.
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.