Narrow Results Clear All
- Communication between Providers 8
- Culture of Safety 15
- Education and Training 5
- Error Reporting and Analysis 22
- Human Factors Engineering 9
- Legal and Policy Approaches 9
- Logistical Approaches 8
- Policies and Operations 1
- Quality Improvement Strategies 15
- Specialization of Care 5
- Teamwork 4
- Clinical Information Systems 10
- Transparency and Accountability 1
- Diagnostic Errors 4
- Discontinuities, Gaps, and Hand-Off Problems 8
- Drug shortages 3
- Fatigue and Sleep Deprivation 3
- Identification Errors 3
- Medical Complications 5
- Medication Errors/Preventable Adverse Drug Events 13
- Psychological and Social Complications 4
- Surgical Complications 7
- Internal Medicine 13
- Nursing 4
- Palliative Care 1
- Pharmacy 7
Health Care Executives and Administrators
- Facility and Group Administrators
Health Care Providers
- Nurses 8
- Physicians 14
Non-Health Care Professionals
- Media 2
- Patients 16
Search results for "Facility and Group Administrators"
- Newspaper/Magazine Article
- Facility and Group Administrators
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.
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.
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.
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.
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.
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.
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.
Laposata M. The Pathologist. September 2017;(34):18-27.
Wallace SC, Mamrol C, Finley E. PA-PSRS Patient Saf Advis. September 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.
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.
Thew J. HealthLeaders Media. June 14, 2017.
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.
Hurt J. Med Econ. April 26, 2017.
Carr S. ImproveDx. April 2017;4:1-4.
Headley M. Patient Saf Qual Healthc. April 5, 2017.
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.