Narrow Results Clear All
Communication between Providers
- Sbar 4
- Communication between Providers 146
- Culture of Safety 107
Education and Training
- Simulators 16
- Students 9
Error Reporting and Analysis
- Never Events 11
- Error Reporting 178
Human Factors Engineering
- Checklists 41
Legal and Policy Approaches
- Regulation 54
- Logistical Approaches 67
- Policies and Operations 7
Quality Improvement Strategies
- Benchmarking 15
- Specialization of Care 44
- Teamwork 50
- Clinical Information Systems 107
- Transparency and Accountability 10
- Alert fatigue 1
- Device-related Complications 67
- Diagnostic Errors 92
- Discontinuities, Gaps, and Hand-Off Problems 92
- Drug shortages 17
- Fatigue and Sleep Deprivation 21
- Identification Errors 44
- Interruptions and distractions 10
- Delirium 1
- Medication Errors/Preventable Adverse Drug Events 252
- MRI safety 4
- Nonsurgical Procedural Complications 20
- Overtreatment 3
- Psychological and Social Complications 72
- Second victims 5
- Surgical Complications 135
- Transfusion Complications 4
- Ambulatory Care 101
- General Hospitals 186
- Long-Term Care 14
- Outpatient Surgery 18
- Patient Transport 7
- Psychiatric Facilities 5
- Allied Health Services 2
- Dentistry 2
- Geriatrics 16
- Obstetrics 19
- Pediatrics 44
- Primary Care 10
- Radiology 16
- Internal Medicine 279
- Nursing 59
- Palliative Care 1
- Pharmacy 185
- Family Members and Caregivers 21
- Health Care Executives and Administrators 573
Health Care Providers
- Nurses 91
- Pharmacists 87
- Physicians 162
Non-Health Care Professionals
- Educators 34
- Engineers 37
- Media 9
- Patients 505
- Asia 1
- Europe 38
- Canada 12
United States of America
United States Federal Government
- Department of Health and Human Services (HHS) 10
- United States Federal Government 14
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Daley J. Colorado Public Radio. February 23, 2018.
Innovations in the prescribing of opioids in the emergency department are needed to change practice and help address the opioid crisis. This news article reports the results of a 10-hospital pilot program, the Colorado Opioid Safety Collaborative, which used alternative pain control approaches to reduce opioid prescriptions by an average of 36%. The program builds on multidisciplinary teamwork to modify pain management in the emergency department. An Annual Perspective highlighted opioid misuse as a patient safety challenge.
ISMP Medication Safety Alert! Acute Care Edition. February 22, 2018;23:1-5.
Myriad system and clinician failures can contribute to medication errors. This newsletter article reviews factors that contribute to nebulized medication administration problems, such as unlabeled solutions, look-alike packaging, equipment misuse, and storage issues. Recommendations to reduce risks include team assessment of barcode scanning processes, communicating orders, and storing vials separately.
Crane M. Medscape Business of Medicine. February 20, 2018.
Vosper H, Lim R, Knight C, Bowie P, Edwards B, Hignett S; CIEHF Pharmaceutical Human Factors Special Interest Group. Clinical Pharmacist. 2018;10(2).
Traditionally, efforts to reduce medical errors have focused on modifying individual behavior rather than systems. This article reviews the use of systems thinking models to address failure and discusses how small problems can combine into organizational failure. The authors suggest that the health care workforce develop human factors engineering competencies to achieve improvements.
Quick Safety. January 22, 2018;(39):1-3.
ISMP Medication Safety Alert! Acute Care Edition. January 11, 2018;23:1-4.
Drug shortages are known to disrupt the safety of care. This newsletter article reports the results of a survey exploring the impact of drug shortages on practice and recommends strategies to help organizations safely manage drug shortages, including standardizing processes and raising awareness among clinicians regarding shortages.
The science of safety: trustees can play a crucial role in fostering a safety culture at their hospitals.
Fairbanks RJ, Krevat SA. Trustee Magazine. January 8, 2018.
Safety sciences offer methods to enhance processes and develop organizational culture. This magazine article reports on safety science approaches that have improved safety in high-risk industries and concepts such as learning from failure and transparency that should be encouraged by leadership in health care.
Rau J. Kaiser Health News. January 5, 2018.
Magee MC, Miller K, Patzek D, Madera C, Michalek C, Shetterly M. PA-PSRS Patient Saf Advis. Dec 2017;14.
Near misses provide unique opportunities to identify and learn from safety hazards. Describing how one organization utilized data on near misses involving barcode medication administration over a 12-year period to reduce barcode-workflow events, this report outlines practices and strategies that contributed to success such as promoting event reporting and applying root cause analysis.
Burger C, Eaton P, Hess K, et al. Patient Saf Qual Healthc. December 12, 2017.
Boodman SG. Washington Post. December 9, 2017.
The prevalence of polypharmacy among older patients represents an important concern for health care safety, as unneeded medications can contribute to patient harm. This newspaper article reports on several strategies to reduce inappropriate medication use in older patients, including desprescribing and brown bag medication review.
ISMP Medication Safety Alert! Acute Care Edition. November 16, 2017;22:1-5.
Texting medication orders is convenient for providers, but there are concerns associated with safety and security risks. This newsletter article reviews the results of a national survey on the use of provider text messaging in health care. Participants reported problems such as misidentification of patients, autocorrection errors, and misunderstood abbreviations that can contribute to medication errors.
New York, NY: ProPublica, Inc; 2017.
Aleccia J, Bailey M. Kaiser Health News. October 26, 2017.
Patient safety in ambulatory hospice care is ill defined. Reporting on safety concerns associated with hospice care, including poor coordination and insufficient family education, this news article discusses how citizen complaints led to government investigations into deficiencies of end-of-life home care.
Szabo L. Kaiser Health News. October 23, 2017.
Overdiagnosis and overtreatment present a challenge to patient safety. This news article reports on the prevalence of overtreatment among patients with cancer, how it can result in patient harm, and patient stories that illustrate the impact of overtreatment. A past PSNet interview discussed the patient safety implications of diagnostic radiology overuse.
ISMP Medication Safety Alert! Acute Care Edition. October 19, 2017;22:1-3.
Quick Safety. October 16, 2017;(37):1-3.
Blank C. Drug Topics. October 13, 2017.
Kuang C. Fast Company. October 4, 2017.
Complicated systems often require more than one change to improve their safety. Poor patient understanding of prescription labels and medication dispensing processes at retail pharmacies contribute to medication errors. This news article discusses a strategy that began with color-coded labels and led to a retail pharmacy implementing redesigned pill bottles that provide an overall prescription regimen.
Headley M. Patient Saf Qual Healthc. October 4, 2017.
Burnout, stress, and personal challenges can affect clinicians' ability to provide safe care. This article explores factors that prevent clinicians from seeking support and provides suggestions for organizations to encourage health care providers to solicit help, such as establishing a culture of wellness, second victim initiatives, substance abuse assistance, and domestic violence programs.