Medical errors

Innovations

Three-Tiered Emotional Support System Generates Positive Feedback From Providers Who Become "Second Victims" of an Unanticipated Clinical Event 06/08/10

A three-tiered system consisting of unit-level support, access to trained peer supporters, and referral to formal counseling services provides emotional support to health care professionals involved in an adverse event, leading to positive anecdotal feedback from these professionals.

Multiple Safeguards in Hospital Intravenous Medication Administration Processes Reduces Dosing Limit Violations and Improves Nurse Efficiency 05/24/10

A hospital revamped its process for administering intravenous medications to incorporate multiple automated and human safeguards, leading to increased adherence to drug dosing limits and the elimination of many error-prone steps involved in manually programming the intravenous infusion pump.

Monthly Multidisciplinary Patient Safety Conferences Improve Hospital Staff Perceptions of Organization's Safety Culture and Increase Reporting of Adverse Events 02/09/10

Monthly patient safety conferences that allow clinicians and all levels of staff to openly discuss adverse events improved staff perceptions of the organization's safety culture and increased the reporting of such events.

Checklist-Guided Process Reduces Surgery-Related Mortality and Complications 01/14/10

A checklist-guided process helps to ensure that surgical teams perform all appropriate care and necessary processes before and after surgery, leading to reductions in surgery-related mortality and complications.

Proactive Reporting, Investigation, Disclosure, and Remedying of Medical Errors Leads to Similar or Lower Than Average Malpractice Claims Costs 12/14/09

A medical center adopted a comprehensive process that includes proactive reporting and investigation of potential errors, full disclosure and apology when errors occur, and fair remedy and compensation, leading to similar or lower than average claims costs.

Pathology Team Provides Patient-Specific Interpretations of Test Results, Reducing Ordering Errors and Speeding Up Diagnostic Process 12/08/09

Pathologists provide a paragraph of patient-specific analysis as a supplement to traditional laboratory test results, leading to fewer ordering errors, time savings, and quicker diagnoses.

Improvement Projects Led by Unit-Based Teams of Nurse, Physician, and Quality Leaders Reduce Infections, Lower Costs, Improve Patient Satisfaction, and Nurse–Physician Communication 12/04/09

Unit-based teams of physicians, nurses, and quality leaders develop and implement unit-specific initiatives designed to improve quality and safety, leading to reductions in infections and pressure ulcers, increased adherence to medication reconciliation standards, more reporting of errors and near-misses, higher patient satisfaction, and better overall nurse/physician communication and teamwork.

Full Disclosure of Medical Errors Reduces Malpractice Claims and Claim Costs for Health System 10/03/09

A multifaceted process for full disclosure of medical errors leads to a significant reduction in claims and claim costs for a health system.

Real-Time, Resident-Specific Medication Information and Alerts, Supported by Medication Safety Teams, Enhance Efficiency and Reduce Medication Errors in Nursing Homes 09/30/09

Real-time, resident-specific medication information and alerts, with support from a medication safety team, enhanced the efficiency of medication administration and reduce medication errors.

Use of Photographs as Second Means of Identifying Patients on Psychiatry Units Virtually Eliminates Medication Errors Related to Misidentification 08/04/09

Use of photographs as a second means of identifying patients on adult and adolescent psychiatry units virtually eliminates medication errors due to patient misidentification.

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