Narrow Results Clear All
- Communication Improvement 1
- Culture of Safety 4
- Education and Training 1
- Error Reporting and Analysis 13
- Human Factors Engineering 1
- Legal and Policy Approaches 9
- Policies and Operations 1
- Quality Improvement Strategies 3
- Specialization of Care 1
- Technologic Approaches 2
- Transparency and Accountability
- Device-related Complications 1
- Diagnostic Errors 2
- Failure to rescue 1
- Identification Errors 1
- Medical Complications 1
- Medication Safety 1
- Nonsurgical Procedural Complications 2
- Second victims 1
- Surgical Complications 4
- Medicine 17
Search results for "Transparency and Accountability"
- Newspaper/Magazine Article
- Transparency and Accountability
Gabler E. New York Times. May 31, 2019.
Pediatric cardiac surgery is highly technical and risky. This newspaper article reports on a poorly performing pediatric cardiac surgery program, concerns raised by staff, and insufficient response from organizational leadership. Lack of data transparency, insufficient resources, and limited program capabilities to support a complex program contributed to poor outcomes for pediatric patients.
Jewett C. Kaiser Health News. May 3, 2019.
Transparency has been heralded as a cornerstone to improvement in health care. This news article reports on a government alternative summary reporting program that allowed medical device makers to conceal safety events and malfunction reports associated with medical devices. A new program that expands access to information about device-related failures will be put in place.
Park A. Time Magazine. January 24, 2019.
This news article reports on the documentary To Err Is Human, which was produced and directed by the son of patient safety leader Dr. John M. Eisenberg. The film is structured around patient safety advocate Sue Sheridan's experience with diagnostic errors that resulted in harm for both her son and husband. It features a wide range of experts who discuss the impact of error on all involved, the role of culture in facilitating both mistakes and progress, and why continued work in health care safety is needed.
Beck DL. ASH Clinical News. December 1, 2018.
Canadian Medical Protective Association. CMPA Perspective. September 2018;10:8-11.
Frontline leadership should model just culture behaviors to encourage reporting and discussion of error to facilitate improvement. This news article uses a medical administration error to examine whether human error, at-risk behavior, or reckless action on the part of a clinician led to the mistake and explores leadership response to the incident to determine accountability in each type of situation.
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.
Wachter R, Kaplan GS, Gandhi T, Leape L. Health Affairs Blog. June 22, 2015.
Transparency is recognized as a key element of safe, patient-centered care. This article offers insights from patient safety experts on how transparency can augment patient safety, barriers such as discomfort with disclosure and fears about negative consequences, and steps leaders can take to achieve greater transparency in their organizations.
Butcher L. Hosp Health Netw. June 2013.
This magazine article explores patient falls and describes strategies to prevent them, including transparency, teach-back, and hallway monitor screens.
Judd A. The Atlanta Journal-Constitution. November 20, 2011.
Allen M. Washington Monthly. March/April 2011.
This magazine article reports on medical errors in the United States health care system and discusses transparency as a tactic to improve patient safety.
Bogdanich W, Rebelo K. New York Times. December 28, 2010;A1.
This article explores inaccuracy of dosage, lack of protocol adherence, and absence of transparency as trends that hinder learning from radiological adverse events.
Leape LL. Perspect Health Reform. New York, NY: The Commonwealth Fund; March 17, 2010.
Of three approaches to enhancing patient safety—regulation/accreditation, financial incentives, and public reporting—this perspective, written by the father of the modern patient safety movement, details how public reporting holds the most potential to stimulate improvement.
Kauffman M, Altimari D. The Hartford Courant. November 15, 2009;Final:A1.
This newspaper article reports that a Connecticut law intended to make hospital errors more transparent has had the opposite effect by making it easier for hospitals to limit publicly available information on adverse events.
Errors test openness at Beth Israel Deaconess. Disclosures will benefit hospital, president insists.
Wen P. Boston Globe. October 27, 2008.
This newspaper article reports on one hospital executive's work on transparency regarding errors and describes reactions to these efforts.
Gulliver D. Herald Tribune. September 3, 2007.
This article describes how the culture around medical errors is evolving to include disclosure and transparency, illustrated by a physician's willingness to discuss a wrong-site surgery.
Rein L. Washington Post. August 30, 2019.
Palmer J. Patient Saf Qual Healthc. May/June 2019.
Organizations must learn from adverse events to prevent similar incidents. Reporting on lessons to be learned from the cascade of failures connected with the preventable death of a patient during an acute asthma attack at the door of a hospital emergency department, this magazine article outlines the importance of effective signage, appropriate security staff placement, and acceptance of the responsibility for failure.
Hixenbaugh M, Ornstein C. Houston Chronicle and Propublica.
This news investigation chronicles a series of incidents in a transplant program that resulted in patient harm. The systemic nature of the problems such as insufficient whistleblower protection, accountability, and follow-up on patient concerns culminated in a change of hospital leadership. A previous PSNet interview with Charles Ornstein discussed the role of media in raising awareness of patient safety issues.
McGrory K, Bedi N. Tampa Bay Times. November 28, 2018.
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.