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Communication between Providers
- Sbar 4
- Communication between Providers 164
- Culture of Safety 35
Education and Training
- Students 1
Error Reporting and Analysis
- Error Reporting 41
Human Factors Engineering
- Checklists 13
- Legal and Policy Approaches 36
- Logistical Approaches 16
- Policies and Operations 1
- Quality Improvement Strategies 72
- Specialization of Care 17
- Teamwork 31
- Clinical Information Systems 33
- Transparency and Accountability 1
- Alert fatigue 2
- Device-related Complications 12
- Diagnostic Errors 24
- Discontinuities, Gaps, and Hand-Off Problems 65
- Drug shortages 2
- Failure to rescue 2
- Fatigue and Sleep Deprivation 3
- Identification Errors 27
- Interruptions and distractions 2
- Medical Complications 16
- Medication Errors/Preventable Adverse Drug Events 64
- Nonsurgical Procedural Complications 4
- Overtreatment 1
- Psychological and Social Complications 26
- Second victims 1
- Surgical Complications 39
- Transfusion Complications 1
- Ambulatory Care 30
- General Hospitals 61
- Long-Term Care 3
- Outpatient Surgery 4
- Patient Transport 3
- Psychiatric Facilities 1
- Internal Medicine 63
- Nursing 12
- Pharmacy 58
- Family Members and Caregivers 15
- Health Care Executives and Administrators 163
Health Care Providers
- Nurses 25
- Pharmacists 31
- Physicians 52
Non-Health Care Professionals
- Media 1
- Patients 134
- Europe 9
- United States of America 301
Search results for "Communication Improvement"
- Newspaper/Magazine Article
- Communication Improvement
DeMarco P. Globe Magazine. November 3, 2018.
This magazine article reports on the preventable death of a patient during an acute asthma attack. Written by the patient's husband, the article outlines the failures that led to her death despite the fact that she was at the door of a hospital emergency department and on the phone with an emergency dispatcher. Factors discussed include overreliance on poorly functioning technology, communication failures, and lack of fail-safes.
MacLean L, Coombs C, Breda K. Nurs Manage. 2016;47:30-34.
ISMP Medication Safety Alert! Acute Care Edition. July 14, 2011;16:1-3.
Wetzel TG. Hosp Health Netw. 2010 Oct;84:41-2, 44, 2.
This article describes how hospital responses to adverse events have affected disclosure process strategies.
PA-PSRS Patient Saf Advis. September 2010;7:76-86.
Analyzing reports of diagnostic errors, this article discusses common causes and provides suggestions for physicians and patients to prevent such events.
Zipperer L, Sykes J. Patient Saf Qual Healthc. March/April 2009;6:28-30,32-33.
This survey explores the varied roles that medical librarians play in searching for and disseminating information on patient safety. The majority of librarians surveyed had actively participated in patient safety initiatives.
ISMP Medication Safety Alert! Acute Care Edition. October 5, 2006;11:1-2.
This article outlines an organizational plan to prepare an effective and just response to medical error.
ISMP Medication Safety Alert! Acute Care Edition. September 7, 2006;11:1-3.
This article discusses the difference between a blame-free and just culture and describes why the latter will effectively sustain and support patient safety efforts.
Nance JJ. ABC News. November 16, 2005.
This article reports on the lessons that medicine is learning from the aviation industry, particularly related to teamwork and communication.
Partnering with families and patient advocates: another line of defense in adverse event surveillance.
ISMP Medication Safety Alert! Acute Care Edition. August 1, 2019;24.
Having family members or patient advocates present during hospitalizations can help prevent errors. This newsletter article suggests that utilizing this risk prevention strategy in peripheral care areas such as radiology and other testing units could also prevent patient harm. Recommendations to ensure success of this approach include communicating with advocates, encouraging them to speak up, and activating a rapid response to patient deterioration.
Colino S. Fam Circle. August 2019;132:66,69.
Patients and families can play a role in ensuring care is effective and safe. This news article recommends ways for patients to reduce risk of errors during a hospitalization, including using a patient portal to identify mistakes, asking questions, bringing an advocate, and working with hospitalists as key care partners.
Butcher L. Managed Care. June 2019;28:37-39.
Inconsistent patient name entry practices in electronic health records can contribute to wrong-patient errors. This magazine article reports on the complex nature of addressing patient-matching discrepancies as an economic, privacy, and technical problem. Improvement strategies include the development and adoption of a national identification program and biometric technology. A WebM&M commentary discussed problems associated with name similarities in the electronic patient record.
Ross C. STAT. May 13, 2019.
Nuisance alarms, interruptions, and insufficient staff availability can hinder effective monitoring and response to acute patient deterioration. This news article reports on how hospital logistics centers are working toward utilizing artificial intelligence to improve clinician response to alarms by proactively identifying hospitalized patients at the highest risk for heart failure to trigger emergency response teams when their condition rapidly declines.
ISMP Medication Safety Alert! Acute Care Edition. February 28, 2019;24.
Medication warnings inform providers and patients about risks associated with medication use. As with other safety strategies, applying a systems approach to medication warnings can help redirect actions and prevent patient harm. This article describes design, content, and language characteristics of successful medication safety warnings. In addition, specific design and user-centered considerations are included to improve the effectiveness of electronic alerting.
Cierniak KH, Gaunt MJ, Grissinger M. PA-PSRS. Patient Saf Advis. 2018;15(4).
The operating room environment harbors particular patient safety hazards. Drawing from 1137 perioperative medication error reports submitted over a 1-year period, this analysis found that more than half of the recorded incidents reached the patient and the majority of those stemmed from communication breakdowns during transitions or handoffs. The authors provide recommendations to reduce risks of error, including using barcode medication administration, standardizing handoff procedures, and stocking prefilled syringes.
Graham J. Kaiser Health News. November 21, 2018.
Patients can identify errors in their medical records that health care providers may not recognize. This news article highlights the importance of patients correcting seemingly simple mistakes such as name misspellings and phone numbers as these errors can contribute to situations that result in patient harm.
Gipson K. PA-PSRS Pa Patient Saf Advis. 2018 Oct 31;15(suppl 1):39-45.
van der Heijde R, Deichmann D. Harv Bus Rev. October 30, 2018.
Aviation continues to provide inspiration for patient safety innovation. This commentary describes a 10-minute team huddle exercise which involves team members rating their own mood status and the leader asking if there are any contextual concerns. In addition, two team members select "knowledge cards" that either test the person's knowledge or assign the person to proactively watch for improvement opportunities during the shift. The results encouraged sharing, situational awareness, and team building.
Peeples L. Pharmacy Practice News. October 10, 2018.
Structured handoffs can reduce communication problems that contribute to medical error. This magazine article reports on how I-PASS implementation can help enhance the quality and completeness of handoffs, highlights the need for pharmacists to be more engaged in handoff improvement, and offers insights for enhancing their role in the process. In a past PSNet interview, Dr. Amy Starmer discussed the implementation and findings of the landmark I-PASS study.
Peskin SM. New York Times. October 4, 2018.
Error disclosures are difficult but important conversations that can have negative consequences for patients, clinicians, and organizations, even when they are done appropriately. This newspaper article offers insights from a doctor who experienced both sides of disclosure, as a physician disclosing an error and as a patient whose physician missed a complication, and discusses how to manage relationships once clinical mistakes are recognized.