Narrow Results Clear All
Communication between Providers
- Sbar 4
- Communication between Providers 145
- Culture of Safety 106
Education and Training
- Simulators 16
- Students 9
Error Reporting and Analysis
- Never Events 11
- Error Reporting 177
Human Factors Engineering
- Checklists 41
Legal and Policy Approaches
- Regulation 54
- Logistical Approaches 67
- Policies and Operations 6
Quality Improvement Strategies
- Benchmarking 15
- Specialization of Care 43
- Teamwork 50
- Clinical Information Systems 107
- Transparency and Accountability 10
- Alert fatigue 1
- Device-related Complications 67
- Diagnostic Errors 90
- Discontinuities, Gaps, and Hand-Off Problems 92
- Drug shortages 16
- Fatigue and Sleep Deprivation 21
- Identification Errors 44
- Interruptions and distractions 10
- Delirium 1
- Medication Errors/Preventable Adverse Drug Events 246
- MRI safety 4
- Nonsurgical Procedural Complications 20
- Overtreatment 2
- Psychological and Social Complications 70
- Second victims 3
- Surgical Complications 135
- Transfusion Complications 4
- Ambulatory Care 95
- General Hospitals 184
- 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 21
- Health Care Executives and Administrators 568
Health Care Providers
- Nurses 91
- Pharmacists 85
- Physicians 161
Non-Health Care Professionals
- Educators 34
- Engineers 38
- Media 9
- Patients 501
- 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 14
Search results for ""
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.
Ready T. HealthLeaders Media. September 26, 2017.
Transitions are an error-prone process. This news article reports that organizational leadership should be engaged in enhancing safety of transitions and facilitating design of sustainable improvements. The article also highlights successful interventions that have benefited from leadership engagement, such as the I-PASS program.
Bendix J. Med Econ. September 25, 2017.
The persistent problem of opioid-related harm calls for changes in pain management practices and system processes in all care settings. This magazine article reports on ways physicians can help proactively recognize and address the potential for patient opioid misuse, such as adherence to guidelines and monitoring patient opioid use. An Annual Perspective discussed the opioid crisis as a patient safety problem.
Estes A. Boston Globe. September 16, 2017.
Psychological safety can empower staff to communicate concerns that affect patient safety. This newspaper article reports on Veterans Affairs staff concerns about safety hazards, consequences whistle-blowers have faced after speaking up about problems, and efforts to protect whistle-blowers and improve the safety of the system.
Landro L. Wall Street Journal. September 12, 2017.
Misdiagnosis has gained recognition as an important patient safety problem. This newspaper article reports on several areas of research and improvement efforts that seek to better understand the roots of diagnostic error and design solutions. Strategies discussed include artificial intelligence, lessons learned initiatives, and data-tracking mechanisms.
Hobson K. Health Shots. National Public Radio. September 8, 2017.
Medication regimen nonadherence can result in patient harm. This news article reports the results of a national poll, which found that a substantial number of patients under the age of 35 do not take their medication as directed. Patients who stopped taking medications without consulting their doctors cited various reasons, including forgetfulness, feeling better, and belief the medication did not work .
ISMP Medication Safety Alert! Acute Care Edition. September 7, 2017;22:1-4.
Workflow processes for compounded sterile preparation can affect patient safety. Discussing how pharmacies have increasingly implemented workflow management systems to automate compounded sterile solution processes, this newsletter article reviews challenges associated with these systems and recommends strategies to reduce risks.
R3 Report. 2017 Aug 29;11:1-7.
Headley M. Patient Saf Qual Healthc. August 21, 2017.
Health care workers face high levels of stress and production pressures, which can contribute to clinician burnout and diminish the safety of care delivery. This commentary describes stressors that affect the psychological health of clinicians, the importance of establishing an organizational culture that supports clinicians, and proactive ways to build clinician resilience in various stressful circumstances.
Mickle K. Glamour Magazine. August 11, 2017.
Wallace SC, Mamrol C, Finley E. PA-PSRS Patient Saf Advis. 2017;14.
Near misses or good catches present organizations with learning opportunities. Using data comparisons run by the Pennsylvania Patient Safety Authority, this article highlights how good catch programs can contribute to significant reductions in harmful events and offers insights from risk managers and patient safety officers regarding elements that are necessary to establish successful good catch initiatives and the culture to support them.
Hamilton WL. Patient Saf Qual Healthc. July 31, 2017.
Miscommunication during care transitions can contribute to medical errors. This article discusses how handoff communication tools can help to improve reliability of information transfer associated with anesthesia practice. The authors emphasize the importance of standardizing the process of perioperative data collection.
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.