An invitation to errorOctober 11, 2011What happens when you’re short staffed and there isn’t anyone to help?
Combating medication verification workarounds in an electronic worldFebruary 11, 2011In the classic report To Err is Human: Building a Safer Health System, the Institute of Medicine reported that at least 44,000 of the deaths that occur in…
Déjà vu all over againJanuary 11, 2014Some people simply can’t learn from the past—even the fairly recent and painful past.
Differences among physicians, risk managers in admitting errorsApril 11, 2010Differences in attitudes among physicians and risk managers about revealing medical errors to patients may diminish the effectiveness of such disclosures, according to a new study published in…
ECRI announces top technology hazards for 2015November 26, 2014The ECRI Institute has announced its Top 10 Health Technology Hazards for 2015, which include alarm hazards, mix-up of IV lines, lack of data integrity, and inadequate reprocessing…
High reliability in healthcare: The chief nursing officer’s critical roleApril 29, 2019CNOs can help lead the way to fewer errors and zero harm. (more…)
Improving health care with systems thinkingSeptember 11, 2008We strive to reach the theoretical goal of perfect patient care. But is defect-free health care possible? Or are avoidable deaths from preventable errors inevitable? Sociologist and organizational theorist Charles Perrow describes…
Learning from mistakesMarch 24, 2017Today’s healthcare organizations need to improve patient safety, which includes effectively communicating information to nurses about safety incidents and how to address them. After all, frontline nurses are…
New report calls for improvement in diagnosingSeptember 24, 2015“Improving Diagnosis in Health Care,” a new report from the Institute of Medicine states “most people will experience at least one diagnostic error in their lifetime, sometimes with…
Our “knowing-doing” gapMarch 11, 2010Something as simple and low – tech as the checklist can help healthcare providers close the knowing – doing gap.
PA catheter controversyJune 11, 2007Standard of care in the ICU – or object of overuse, abuse, and misuse? The authors explain why they believe PA catheter use may harm more critically ill…
Quality: A moral primerJune 7, 2016Research reports that one in three deaths in the United States is due to medical error, much of which is due to sloppy, hasty, or inept care and…
Responding to a sentinel eventOctober 11, 2008Sentinel events happen even in the best hospitals. Do you know what these events are and how to handle them?
Study: Reporting medical errors may help reduce them in multi-site clinical practicesOctober 11, 2012Documenting adverse events improves perceptions of safety and may decrease incidents in multi-site clinical practices, according to a study from researchers at the University of Pennsylvania. Read more.
Take Note – March 2008March 11, 2008Updated guidelines on end-of-life care To improve the quality of palliative end-of-life care, the American College of Physicians has revised its guidelines. According to the new recommendations, clinicians…
The high cost of medical errorsAugust 11, 2010According to “The Economic Measurement of Medical Errors,” medical errors cost the US $19.5 billion in 2008. Read more here.
When something goes wrong: how to disclose an errorOctober 11, 2011How should patients learn about an error?
