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Search results for "Non-Health Care Professionals"
- Newspaper/Magazine Article
- Non-Health Care Professionals
Gawande A. New Yorker. November 12, 2018.
In this magazine article, Atul Gawande describes a range of frustrations physicians experience as digitization becomes more widespread in health care. He elaborates upon several elements of electronic health record use that can degrade care processes and create conditions for errors, such as burnout, lack of patient-centeredness, and alert fatigue.
Parikh R. MIT Technol Rev. October 23, 2018.
Computerized decision support and artificial intelligence (AI) are being utilized to enhance decision-making in health care. This magazine article explains how artificial intelligence presents clinicians with an opportunity to improve practice by reducing cognitive load when determining appropriate diagnoses and treatment decisions.
Mix-ups between epidural analgesia and IV antibiotics in labor and delivery units continue to cause harm.
ISMP Medication Safety Alert! Acute Care Edition. October 4, 2018;23:1-4.
Increased urgency to prevent maternal mortality has uncovered various factors that diminish safety. This newsletter article reports on incidents involving the accidental misuse of epidural analgesia and intravenous antibiotics in labor and delivery care, describes contributing factors (e.g., health technology missteps, barcoding mistakes, and look-alike medications), and offers improvement strategies to mitigate harm.
Biel L. ProPublica. October 2, 2018.
This news article reports on systemic weaknesses that enabled a surgeon with poor skills to continue to perform procedures after numerous surgical errors that resulted in patient harm. A past PSNet perspective explored the risk of recurring medicolegal events among providers who have received unsolicited patient complaints, faced disciplinary actions by medical boards, or accumulated malpractice claims.
Quick Safety. October 1, 2018;(45):1-2.
This newsletter article reviews common problems related to patient identification and recommends strategies to ensure verification actions are a part of daily practice. Highlighted suggestions focus on system-level approaches that reduce the potential for incorrect patient data to be entered and proliferate, such as use of frontline confirmation processes and duplicate record monitoring. A WebM&M commentary discussed an incident involving a wrong-patient order in an electronic record system.
Sederstrom J. Drug Topics. September 17, 2018.
Medication errors continue to be a worldwide patient safety challenge that requires both systems and individual practice strategies for improvement. This magazine article describes how pharmacists can address failures associated with processing, dosing, care transitions, and information sharing to prevent medication errors.
Students have a key role in a culture of safety: analysis of student-associated medication incidents.
ISMP Medication Safety Alert! Acute Care Edition. July 26, 2018;23:1-4.
Previous studies have discussed concerns associated with new clinician involvement in care delivery. This data analysis highlights how organizational culture affects student-related errors and summarizes the positive contribution students bring to medication safety, including new perspectives, recently acquired evidence, and a willingness to ask questions.
Arndt RZ. Mod Healthc. July 14, 2018.
Similarities in patient names and clinical situations can result in medical errors. Discussing how digital technologies can exacerbate patient identification problems, this magazine article describes unique elements of information systems that enable mistakes to spread quickly, outlines costs associated with patient mismatches, and recommends improvement strategies such as use of unique patient identifiers. A past WebM&M commentary reviewed an incident involving a patient mix-up.
ISMP Medication Safety Alert! Acute Care. July 12, 2018;23:1-4.
Smart pumps are employed throughout health care, but their design can challenge safety. Reporting results of a national survey, this newsletter article outlines how smart pump data is being used to improve compliance and suggests ways organizations can enhance the value of analytics to inform frontline practice improvement. A previous WebM&M commentary discussed a smart infusion pump error that resulted in patient harm.
The Economist. June 7, 2018.
Artificial intelligence (AI) can improve the timeliness and accuracy of decision making in health care. This magazine article reports on how AI use in medicine can affect diagnosis of cancers, stroke, and cardiac arrhythmia. The piece underscores that though these improvements may look impressive, human knowledge will still be necessary to achieve the full benefit of AI applications for health care improvement.
ISMP Medication Safety Alert! Acute Care Edition. May 31, 2018;23:1-4.
Smart pumps offer both benefits and drawbacks that can affect medication safety. This newsletter article explores missteps related to lack of compliance with setting hard stops to protect patients when using unique intravenous medication concentrations. Recommendations to prevent errors include using standardized dosing concentrations as often as possible, adhering to metric unit dosing requirements, and verifying pump programming settings.
Burt A, Volchenboum S. Harv Bus Rev. May 8, 2018.
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.
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.
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.
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.
Magee MC, Miller K, Patzek D, Madera C, Michalek C, Shetterly M. PA-PSRS Patient Saf Advis. December 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.
ISMP Medication Safety Alert! Acute Care Edition. October 19, 2017;22:1-3.