An invitation to error
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Combating medication verification workarounds in an electronic world
In 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 again
Some people simply can’t learn from the past—even the fairly recent and painful past.
Differences among physicians, risk managers in admitting errors
Differences 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 2015
The 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 role
CNOs can help lead the way to fewer errors and zero harm. (more…)
Improving health care with systems thinking
We 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 mistakes
Today’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 diagnosing
“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” gap
Something as simple and low – tech as the checklist can help healthcare providers close the knowing – doing gap.
PA catheter controversy
Standard 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 primer
Research 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 event
Sentinel 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 practices
Documenting 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 2008
Updated 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 errors
According 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 error
How should patients learn about an error?
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