Common Symptoms, Uncommon Causes: Reducing Misdiagnosis on the Front Lines

Common Symptoms, Uncommon Causes: Reducing Misdiagnosis on the Front Lines

Posted by  | Preventing Patient Harm

In 2013, a 52-year-old man went to an emergency department complaining of dizziness. Physicians evaluated him, decided that it was a benign condition — as it usually is — and sent him home. Days later, it became apparent that this was no harmless event. He suffered a significant stroke, with permanent disability as the result.(...)

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Thinking Outside the Hospital: A Call to Action for Outpatient Safety

Thinking Outside the Hospital: A Call to Action for Outpatient Safety

Posted by  | Patient-Centered Care, Preventing Patient Harm

Health care has been thinking about medical errors for nearly 20 years, starting with the Institute of Medicine’s 1999 report “To Err is Human.” This and other work across the country have correctly shed light upon such medical errors as amputation of the wrong limb, inpatient adverse drug events and hospital-acquired infections, and we have(...)

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How the Flint Water Crisis Is a Cautionary Tale for Health Care

How the Flint Water Crisis Is a Cautionary Tale for Health Care

Posted by  | Designing Safer Systems, Organizational and Cultural Change, Preventing Patient Harm

There has been no shortage of blame for the poisoning of Flint, Michigan's water supply. In March, a governor-appointed task force issued a report that rebuked local, state and federal authorities for their actions — and inactions — that created the public health crisis. Then, in late April, state prosecutors announced the first charges in the(...)

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What Teenage Patients — and Their Parents — Want from Their Care Team

What Teenage Patients — and Their Parents — Want from Their Care Team

Posted by  | Patient-Centered Care

For anyone with a serious medical condition, frequent hospitalizations and clinic visits can have a profoundly disruptive impact. Yet adolescent and teenage patients have a uniquely challenging experience. A boy who would otherwise be playing on a soccer team or performing in a play may be undergoing chemotherapy. A girl who had expected to be(...)

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It’s Not All About the Checklist: The Power of Believing and Belonging

It’s Not All About the Checklist: The Power of Believing and Belonging

Posted by  | Organizational and Cultural Change, Preventing Patient Harm

Trine Engebretsen was clinging to life. It was the early 1980s, and the girl had a genetic liver disorder that would kill her if she did not get a transplant. Yet, as she waited for a matching liver, some providers called her parents and urged them not to allow the surgery. They cautioned them that(...)

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5 Lessons for Creating Health Care Performance Dashboards

5 Lessons for Creating Health Care Performance Dashboards

Posted by  | Measurement of Safety and Quality

In recent years, Johns Hopkins Medicine has grown increasingly sophisticated in its use of patient safety and quality dashboards, not just to spur internal improvement efforts but also to increase transparency with the public about our performance. In 2013, we launched an internal dashboard for our health system’s 41,000 employees, sharing our performance data on(...)

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