| 1. | In Conversation with…Peter J. Pronovost, MD, PhD
IN CONVERSATION WITH… (June 2005)
Excerpt: "Peter J. Pronovost, MD, PhD, is Medical Director of the Johns Hopkins Center for Innovation in Quality Patient Care. A practicing anesthesiologist and critical care physician, he has appointments in both The Johns Hopkins University School of Medicine and its Bloomberg School of Public Health. Dr. Pronovost's research, which has focused on how to improve patient safety and quality in the ICU setting, has been characterized by a blend of methodologic sophistication and practical attention to the details of making change happen and making it stick. His many contributions include studies of the value of intensivists, of the use of daily goal cards on safety and communication, of an executive adopt-a-unit strategy, and of a comprehensive unit-based safety program. For this work, much of which has been supported by AHRQ, he was awarded the John M. Eisenberg Award in Research Achievement in 2004." |
| 2. | In Conversation with…Jack Barker, PhD
IN CONVERSATION WITH… (January 2006)
Excerpt: "Jack Barker, PhD, is Vice President of Research and Development for Mach One Leadership and a commercial pilot for a major airline. Dr. Barker began his career in the Air Force and proceeded to get his doctorate in cognitive psychology. His research has centered on high-performance teams, crew resource management (CRM), and training. He has trained hundreds of commercial airline pilots, as well as pilots and others working for NASA in the Space Shuttle program and Mars mission. His company, like several others, works with health care providers and organizations in an effort to translate aviation safety principles to health care." |
| 3. | In Conversation With...Donald A. Norman, PhD
IN CONVERSATION WITH... (November 2006)
Excerpt: "Don Norman, PhD, is well known for his books "The Design of Everyday Things" and "Emotional Design." Although not focused on health care, his work introduced many in health care to the concepts of human factors engineering and to the importance of thoughtful design in ensuring that technology is used for its intended purposes. He is cofounder of the Nielsen Norman Group, professor at Northwestern University, and former vice president of Apple Computer. Dr. Norman is now writing "The Design of Future Things," discussing the role that automation will play in our everyday lives. We asked Dr. Norman to speak with us about human-centered design." |
| 4. | In Conversation with…John Banja, PhD
IN CONVERSATION WITH… (February 2006)
Excerpt: "John Banja, PhD, is Assistant Director for Health Sciences and Clinical Ethics and Associate Professor of Clinical Ethics at Emory University School of Medicine. Dr. Banja, whose doctorate is in philosophy, is currently participating in AHRQ-funded studies designed to help clinicians communicate more effectively in emotionally charged situations after errors or unforeseen outcomes. His book, Medical Errors and Medical Narcissism, covers issues around the appropriate, ethical disclosure of medical errors by health care professionals." |
| 5. | In Conversation with...J. Bryan Sexton, PhD, MA
IN CONVERSATION WITH... (December 2006)
Excerpt: "J. Bryan Sexton, PhD, MA, is Assistant Professor, Department of Anesthesiology and Critical Care Medicine, at the Johns Hopkins University School of Medicine. Trained as a social psychologist, he has become one of the world's foremost authorities on the role of culture in patient safety. He developed the widely used Safety Attitudes Questionnaire and is one of the lead investigators of the Michigan Keystone ICU project, which aims to change practice and culture in intensive care units (ICUs) throughout the state. His research examines the connections between attitudes, behaviors, and outcomes in high-risk team environments, particularly aviation and medicine. We asked him to speak with us about safety climate surveys and efforts to change safety culture." |
| 6. | PCA Overdose
CASE & COMMENTARY (July 2005)
Excerpt: "Following surgery, a woman receives morphine via a patient-controlled analgesia (PCA) pump. A few hours after arriving on the floor, she is found barely breathing." |
| 7. | Coming Up Short
CASE & COMMENTARY (October 2008)
Excerpt: "Well-child checks failed to determine that the growth of a young immigrant girl was severely behind the curve. At the age of 12, routine lab tests showed a TSH of 834—indicating severe hypothyroidism." |
| 8. | Wrong Route for Nutrients
CASE & COMMENTARY (July 2008)
Excerpt: "An elderly man receiving feedings through a percutaneous enterostomy tube was prescribed intravenous total parenteral nutrition (TPN). A licensed practical nurse (LPN) mistakenly connected the TPN to the patient's enterostomy tube. His daughter (a retired nurse) asked her about it, and the RN on duty confirmed the error. The LPN disconnected the mistakenly placed (and now contaminated) line, but then prepared to attach it to the intravenous catheter. Luckily, both the patient's daughter and the RN were present and stopped her." |
| 9. | No Blood, Please
CASE & COMMENTARY (May 2004)
Excerpt: "Understanding that she may lose her life without it, a woman severely injured in a collision rejects a blood transfusion for religious reasons. However, her parents persuade the physicians otherwise, and the woman lives." |
| 10. | To Resuscitate or Not?
CASE & COMMENTARY (January 2004)
Excerpt: "A patient receiving end-of-life care, whose code status was DNR, encounters a potentially life-threatening medication error." |
| 11. | Misread Label
CASE & COMMENTARY (November 2003)
Excerpt: "An infant born with sluggish breathing is given Lanoxin instead of naloxone, and dies of digoxin toxicity." |
| 12. | One ACE Too Many
CASE & COMMENTARY (July 2006)
Excerpt: "A patient presenting to the ED with chest pain was ruled out for MI, and discharged on an ACE inhibitor. Two weeks later, he returns with a critically elevated potassium level, has a cardiac arrest, and dies." |
| 13. | Cups of Error
CASE & COMMENTARY (May 2006)
Excerpt: "A nursing student administers the wrong 'cup' of medications to an elderly man. A different student discovered the error when she reviewed the medicines in her patient's cup and noticed they were the wrong ones." |
| 14. | Check the Bags
CASE & COMMENTARY (September 2003)
Excerpt: "A patient given diltiazem rather than saline suffers severe bradycardia requiring temporary pacemaker." |
| 15. | Shake Well
CASE & COMMENTARY (September 2003)
Excerpt: "Failure to shake a bottle leads to a toxic level of carbamazepine in a patient being treated for seizure disorder." |
| 16. | Not a Miscarriage
CASE & COMMENTARY (June 2003)
Excerpt: "A woman was told she miscarried, even though she was still pregnant." |
| 17. | The Role of Health Literacy in Patient Safety
PERSPECTIVE (February 2009)
Excerpt: "Clear health communication is increasingly recognized as essential for promoting patient safety. Yet according to a recent Joint Commission report, What Did the Doctor Say? Improving Health Literacy to Protect Patient Safety, communication problems among health care providers, patients, and families are common and a leading root cause of adverse outcomes. Addressing health literacy—the capacity of individuals to obtain, process, and understand basic health information and services needed to make appropriate health decisions—has become a primary objective for many health systems in order to protect patients from harm. " |
| 18. | Getting Into Patient Safety: A Personal Story
PERSPECTIVE (August 2006)
Excerpt: "My journey into patient safety began in 1972. It was born of serendipity enabled by the good fortune of extraordinary mentors, an environment that supported exploration and allowed for interdisciplinary teamwork, and my own intellectual curiosity. The..." |
| 19. | The Unfinished Patient Safety Agenda
PERSPECTIVE (July 2005)
Excerpt: "The goal set by the Institute of Medicine (IOM) in 1999 to reduce medical errors by half within 5 years has not been achieved. Opinion polls of consumers and health professionals show that concerns about patient safety remain high. Yet only 16% of hospital..." |
| 20. | Organizational Change in the Face of Highly Public Errors—I. The Dana-Farber Cancer Institute Experience
PERSPECTIVE (May 2005)
Excerpt: "A decade ago, two tragic medical errors rocked one of the world’s great cancer hospitals, Dana-Farber Cancer Institute (DFCI) in Boston, to its core. The errors led to considerable soul searching and, ultimately, a major change in institutional practices a..." |
