Narrow Results Clear All
Communication between Providers
- Sbar 4
- Communication between Providers 147
- Culture of Safety 107
Education and Training
- Simulators 16
- Students 9
Error Reporting and Analysis
- Never Events 11
- Error Reporting 181
Human Factors Engineering
- Checklists 42
Legal and Policy Approaches
- Regulation 53
- Logistical Approaches 67
- Policies and Operations 7
Quality Improvement Strategies
- Benchmarking 15
- Specialization of Care 44
- Teamwork 50
- Clinical Information Systems 114
- Transparency and Accountability 12
- Alert fatigue 1
- Device-related Complications 69
- Diagnostic Errors 95
- Discontinuities, Gaps, and Hand-Off Problems 92
- Drug shortages 18
- Fatigue and Sleep Deprivation 21
- Identification Errors 44
- Interruptions and distractions 10
- Delirium 1
- Medication Errors/Preventable Adverse Drug Events 255
- MRI safety 4
- Nonsurgical Procedural Complications 20
- Overtreatment 3
- Psychological and Social Complications 73
- Second victims 5
- Surgical Complications 136
- Transfusion Complications 4
- Ambulatory Care 102
- General Hospitals 189
- Long-Term Care 14
- Outpatient Surgery 18
- Patient Transport 7
- Psychiatric Facilities 5
- Allied Health Services 2
- Dentistry 2
- Geriatrics 16
- Obstetrics 20
- Pediatrics 46
- Primary Care 10
- Radiology 16
- Internal Medicine 280
- Nursing 59
- Palliative Care 1
- Pharmacy 186
- Family Members and Caregivers 21
- Health Care Executives and Administrators 574
Health Care Providers
- Nurses 91
- Pharmacists 87
- Physicians 167
Non-Health Care Professionals
- Educators 35
- Engineers 37
- Media 9
- Patients 513
- Asia 1
- Europe 39
- Canada 12
United States of America
United States Federal Government
- Department of Health and Human Services (HHS) 10
- United States Federal Government 14
Search results for ""
Kowalczyk L. Boston Globe. May 27, 2018.
Pediatric patients are particularly vulnerable to medication errors. This news article reports on serious medication errors that occurred at Children's Hospital in 2017, the underlying system failures that contributed to the incidents, and challenges to implementing new policies meant to prevent similar errors.
Mukherjee S. New York Times Magazine. May 9, 2018.
Checklists can coordinate action and communication to augment safety, but human and system factors may hinder their effectiveness. This magazine article reports on how the checklist phenomenon evolved into a global patient safety effort and spotlights the impact of human behavior on reliable implementation of checklist programs in different care environments.
Burt A, Volchenboum S. Harv Bus Rev. May 8, 2018.
O'Loughlin E. New York Times. April 30, 2018.
Large-scale adverse events should lead to system examination and improvement. This newspaper article reports on misread cervical cancer tests that resulted in 208 women receiving false negative results over a 4-year period from a publicly funded smear test program in Ireland and the government inquiry launched in response to this large-scale failure.
Porter S. HealthLeaders Media. April 26, 2018.
Overreliance on technology can result in harmful medication mistakes. Reporting on a 10-fold medication overdose that led to the death of a patient with dementia, this news article describes how the hospital changed their processes to improve medication safety, which included restructuring medication safety leadership, modifying the electronic health record to address alert overrides, and enhancing information sharing to support learning and transparency.
Crouch M. Reader's Digest. April 2018.
Involving patients in their care can help improve safety. This magazine article provides 34 tips from leading patient safety experts to assist patients in this role. Tactics include considering a second opinion, bringing an up-to-date medication list, and repeating information back to providers to reduce misunderstandings.
The next generation of doctors may be learning bad habits at teaching hospitals with many safety violations.
Blau M. STAT. April 20, 2018.
The hidden curriculum, staff burnout, and other organizational norms contribute to behaviors that put both care teams and patients at risk. Reporting on clusters of safety violations the Centers for Medicare and Medicaid Services found at teaching hospitals, this news article suggests that trainees who learn in environments where patients receive unsafe care may perpetuate poor practices and reviews how teaching hospitals are working to change behavior and educate trainees about patient safety.
ISMP Medication Safety Alert! Acute Care Edition. April 5, 2018;23:1-5.
Smart pumps are considered an important tool to improve medication safety in the hospital environment. This newsletter article summarizes the results of two national surveys on smart infusion pump use to highlight current concerns and challenges to generating improvements. Irrelevant alarms and out-of-date drug libraries were among the problems identified by survey participants.
Pharmacy Practice News. April 4, 2018.
Despite considerable effort, medication errors continue to occur and result in patient harm. Summarizing reports of medication mistakes submitted to the Institute for Safe Medication Practices for analysis, this news article describes types of problems, prevention strategies, and technologies that can reduce risks.
Wachter R, Goldsmith J. Harv Bus Rev. March 30, 2018.
Increased workload associated with electronic health record (EHR) documentation contributes to physician burnout. Describing challenges associated with poor user interface of EHRs, this magazine article recommends use of artificial intelligence, redesigning workflow, and enhancing alert systems to improve the usefulness of EHRs.
Quick Safety. March 27, 2018;(40):1-2.
Falls are a common patient safety concern for adults but are rarely discussed as a threat to newborn safety. This newsletter article provides a definition for a newborn fall or drop, highlights factors that increase risks of such incidents, and offers recommendations to augment safety such as rounding to monitor parent fatigue and reporting of events to inform improvements.
Lamas D. New York Times. March 27, 2018.
Advance care planning can affect patient safety if the information is unheeded, unavailable, or unread. Reporting on a physician's experience with a patient who nearly received an unwanted intubation due to poor electronic health record data quality and design, this newspaper article describes problems associated with lack of standards for advance care planning documentation and the inability to access advance directives.
Boodman SG. Washington Post. March 26, 2018.
Although providing patients with access to physician notes and test results supports transparency and patient engagement, it can also introduce certain challenges. This newspaper article reports on unintended psychological stresses associated with direct patient access to test results without appropriate contextual information. Improvement strategies include use of graphics, timely patient-centered communication, and scheduling appointments to discuss results. A PSNet perspective explored how patient-facing technologies can empower patients and improve safety.
Liberatore K. PA-PSRS Patient Saf Advis. 2018 March;15.
Latex products are widely available in hospitals and represent a persistent threat to patients with latex allergies. Drawing from 616 reported latex-related events, this investigation found that more than half of the incidents were associated with indwelling urinary catheter use. Tracking staff awareness of latex allergies, purchasing latex-safe alternatives, and improving handoff documentation of patient allergies are possible risk reduction strategies. A WebM&M commentary discussed allergy documentation in patient health records.
Bartolone P. Kaiser Health News. March 16, 2018.
Drug shortages may require clinicians, pharmacists, and hospitals to divert from standard processes to address gaps. This news article reports how reduced opioid production as an approach to address the opioid crisis has led to shortages and subsequent patient harm, such as insufficient pain management for surgical, cancer, and trauma patients.
Montagne R. Weekend Edition Sunday. National Public Radio. March 11, 2018.
Maternal death is a sentinel event. This news audio segment reports on childbirth-related death in the United States and firsthand accounts of complications associated with childbirth, such as infection. The interview also discusses how misdiagnosis contributes to the severity of problems. This piece is part of an ongoing series on the safety of maternal care.
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.
Carr S. ImproveDx. February 2018;5:1-4.
Lack of attention to patient context can affect care safety. This newsletter article reports concerns associated with accurate diagnosis that transgender patients may encounter. The author discusses how bias, poor communication, and uncertainty contribute to potential problems and suggests that patient-centered respectful care is key to improving diagnosis.