In 1996, the Institute for Safe Medication Practices (ISMP) began describing cases of inadvertent intravenous (IV) administration of liquid substances meant for administration via feeding tubes (Using oral syringes, 1996). Of course, incidents had been happening long before that time, putting patients who simultaneously have IV lines and small-bore nasogastric (NG) feeding tubes or percutaneously inserted gastric tubes at risk.

Announcing our 39th Annual Health Care Quality & Patient Safety Conference

Although recent publications have enhanced our understanding of the second victim phenomenon, many questions remain unanswered. In an effort to explain this possible career-ending circumstance, the vast majority of the literature focuses on describing the second victim experience.

A medical malpractice claims review identifies key contributing factors related to harm in the diagnosis and treatment of breast cancer.

The National Practitioner Data Bank (NPDB or Data Bank)—the nation’s leading source for verifying practitioners’ licensure, clinical privileges, disciplinary events, and malpractice payment histories—opened its doors a quarter century ago, on September 1, 1990. It now contains well over one million reports, more than 40% of which concern physicians. Other reports concern dentists, nurses, pharmacists, chiropractors, and all other types of licensed practitioners. The Data Bank’s information is rated as accurate, timely, and appropriate by almost all users, whether they are required by law to obtain Data Bank information or do so voluntarily.

The modern concept of informed consent was born barely a century ago in Schloendorff v. Society of New York Hospital—a 1914 case establishing that procedures performed on a person without the patient’s explicit permission are a form of battery. The notion that risks and alternatives must be disclosed to a patient was established in 1957 in Salgo v. Leland Stanford Jr. University Board of Trustees. That idea was further refined in 1972 in Canterbury v. Spence to specify that the risks disclosed should include those that a reasonable patient might want to know.

As decreasing reimbursement rates continue to flog hospital budgets, organizations struggle to find ways to reduce their costs. As labor represents approximately 60% of hospital expenditures, staffing remains a prime target for reductions.

The benefits of health information exchange (HIE), including cost reduction and improvements to patient care quality, are growing (Ben-Assuli, O., Shabtai, I., & Leshno, M., 2013; Weill Cornell Medical College, 2014; Regenstrief Institute, 2015), but small to midsize physician practices may not be certain if they should join their statewide, regional, or community HIE organization.

The reality of effective patient care calls for more than learning medical knowledge and clinical facts; it requires successful collaboration within the healthcare team. This is especially true in the context of an increasingly complex and multifaceted healthcare system that requires the ability to skillfully navigate and utilize resources for optimal patient outcomes.

In simplest terms, the adage that we must learn from our mistakes is the core principle of the patient safety movement. Acknowledging that human error is inevitable opens the door to improvement. Progress starts with analyzing errors, understanding how to make systems safer and more reliable, and then sharing that knowledge throughout organizations to protect patients from being harmed in the future.