Events that inspired change: the importance of sharing what happened to stop it from happening again.

Eugene Myers; Caitlyn Allen

Commentary

Events that inspired change: the importance of sharing what happened to stop it from happening again.

May 3, 2023

Myers E, Allen C. Patient Saf. 2023;5(1):62-63.

View more articles from the same authors.

Event reporting is core to identifying system-level problems that could harm patients. This article shares several instances of learning from event reports submitted in the state of Pennsylvania to illustrate the value of reporting in patient safety.

Free full text

Related Resources From the Same Author(s)

Assessment of fidelity in interventions to improve hand hygiene of healthcare workers: a systematic review.

March 16, 2016

Rethinking rapid response teams.

September 29, 2010

The role of failure mode and effects analysis in health care.

September 24, 2014

Body of evidence: do autopsy findings impact medical malpractice claim outcomes?

April 29, 2020

Weaving quality improvement and patient safety skills into all levels of medical training: an annotated bibliography.

April 23, 2014

Measuring adverse events in hospitalized patients: an administrative method for measuring harm.

September 7, 2016

Cascade iatrogenesis: factors leading to the development of adverse events in hospitalized older adults.

September 23, 2009

Determining the state of knowledge for implementing the Universal Protocol recommendations: an integrative review of the literature.

August 18, 2010

Leveraging the continuum: a novel approach to meeting quality improvement and patient safety competency requirements across a large department of medicine.

November 14, 2018

Graduate medical education's new focus on resident engagement in quality and safety: will it transform the culture of teaching hospitals?

August 6, 2014

Lessons learned from medical malpractice claims involving critical care nurses.

August 5, 2020

Improving patient safety through transparency.

November 6, 2013

Inpatient Notes: mistakes in the hospital—communicating, apologizing, and beyond.

January 18, 2017

A survey of outpatient internal medicine clinician perceptions of diagnostic error.

February 5, 2020

A piece of my mind. Changing the narrative.

July 27, 2016

The Institute for Safe Medication Practices and poison control centers: collaborating to prevent medication errors and unintentional poisonings.

June 10, 2015

Clinical triggers: an alternative to a rapid response team.

March 4, 2009

Bridging the gap: a framework and strategies for integrating the quality and safety mission of teaching hospitals and graduate medical education.

June 17, 2015

Anatomy of an incident disclosure: the importance of dialogue.

October 3, 2012

Responding to medical errors — implementing the modern ethical paradigm.

January 31, 2024

Aging stigma and the health of US adults over 65: what do we know?

January 10, 2024

Identifying hospital-wide harm: a set of ICD-9–CM-coded conditions associated with increased cost, length of stay, and risk of mortality.

December 17, 2014

Parent participation in morbidity and mortality review: parent and physician perspectives.

June 22, 2022

Consensus statement on effective communication of urgent diagnoses and significant, unexpected diagnoses in surgical pathology and cytopathology from the College of American Pathologists and Association of Directors of Anatomic and Surgical Pathology.

October 26, 2011

Establishing psychological safety in clinical supervision: multi-professional perspectives.

May 11, 2022

Differentiating between detrimental and beneficial interruptions: a mixed-methods study.

November 9, 2016

Patient safety indicators for judging hospital performance: still not ready for prime time.

February 24, 2016

Use of a novel, modified fishbone diagram to analyze diagnostic errors.

July 16, 2014

A description of medical malpractice claims involving advanced practice providers.

July 15, 2020

Dropping the baton during the handoff from emergency department to primary care: pediatric asthma continuity errors.

September 9, 2009

How communication among members of the health care team affects maternal morbidity and mortality.

January 18, 2017

Financial incentives and mortality: taking pay for performance a step too far.

March 16, 2016

A 'Communication and Patient Safety' training programme for all healthcare staff: can it make a difference?

January 30, 2005

Pharmacy dispensing of electronically discontinued medications.

December 5, 2012

Building an ambulatory safety program at an academic health system.

May 15, 2019

Simple strategies to avoid medication errors.

March 21, 2007

Safety concerns of hospital-based new-to-practice registered nurses and their preceptors.

June 23, 2010

Older patients' understanding of emergency department discharge information and its relationship with adverse outcomes.

March 2, 2011

Automated detection of harm in healthcare with information technology: a systematic review.

September 29, 2010

Older veterans and emergency department discharge information.

October 10, 2012

Governing board, C-suite, and clinical management perceptions of quality and safety structures, processes, and priorities in US hospitals.

May 7, 2014

Empowering telemetry technicians and enhancing communication to improve in-hospital cardiac arrest survival.

October 4, 2023

Teaching about how doctors think: a longitudinal curriculum in cognitive bias and diagnostic error for residents.

September 25, 2013

Conducting safety research safely: a policy-based approach for conducting research with peer review protected material.

January 13, 2021

Creating a distraction simulation for safe medication administration.

September 3, 2014

Apology laws and malpractice liability: what have we learned?

July 8, 2020

Reducing anticoagulant medication adverse events and avoidable patient harm.

April 9, 2008

Managing unnecessary variability in patient demand to reduce nursing stress and improve patient safety.

June 8, 2005

A medical resident–pharmacist collaboration improves the rate of medication reconciliation verification at discharge.

September 30, 2015

Hospital quality and patient safety competencies: development, description, and recommendations for use.

January 30, 2005

Patient harm during COVID-19 pandemic: using a human factors lens to promote patient and workforce safety.

December 23, 2020

Administrative compensation for medical injuries: lessons from three foreign systems.

August 3, 2011

The medical liability climate and prospects for reform.

November 19, 2014

Follow-up of abnormal screening mammograms among low-income ethnically diverse women: findings from a qualitative study.

December 8, 2008

Improving safety during transitions of care through the use of electronic referral loops to receive and reconcile health information.

May 10, 2023

Improving clinician well-being and patient safety through human-centered design.

March 8, 2023

Closing the loop with ambulatory staff on safety reports.

December 4, 2019

Oncology medication safety: a 3D status report 2008.

November 5, 2008

Measurement and training of TeamSTEPPS dimensions using the Medical Team Performance Assessment Tool.

January 30, 2013

The introduction of computerized physician order entry and change management in a tertiary pediatric hospital.

November 16, 2005

Bridging leadership roles in quality and patient safety: experience of 6 US academic medical centers.

March 22, 2017

The RCA ReCAst: a root cause analysis simulation for the interprofessional clinical learning environment.

July 14, 2021

Inaccuracy of ECG interpretations reported to the poison center.

March 23, 2011

What prevents incident disclosure, and what can be done to promote it?

August 31, 2011

What do patients and relatives know about problems and failures in care?

January 18, 2012

Liability impact of the hospitalist model of care.

November 5, 2014

The impact of health information management professionals on patient safety: a systematic review.

December 22, 2021

Creating psychological safety in interprofessional simulation for health professional learners: a scoping review of the barriers and enablers.

May 18, 2022

What every graduating resident needs to know about quality improvement and patient safety: a content analysis of 26 sets of ACGME milestones.

July 18, 2018

Gender bias in risk management reports involving physicians in training - a retrospective qualitative study.

November 9, 2022

Reducing preventable medication safety events by recognizing renal risk.

May 14, 2008

Effectiveness of a course designed to teach handoffs to medical students.

September 8, 2010

Pain as the neglected patient safety concern: five years on.

May 18, 2016

Discontinuation of outpatient medications: implications for electronic messaging to pharmacies using CancelRx.

December 7, 2022

Interprofessional learning in multidisciplinary healthcare teams is associated with reduced patient mortality: a quantitative systematic review and meta-analysis.

January 24, 2024

The incorporation of patient safety into board certification examinations.

April 12, 2006

Using a multi-method, user centred, prospective hazard analysis to assess care quality and patient safety in a care pathway.

July 4, 2007

Using patient safety reporting systems to understand the clinical learning environment: a content analysis.

January 9, 2019

The next organizational challenge: finding and addressing diagnostic error.

March 5, 2014

Improving sepsis care through systems change: the impact of a medical emergency team.

March 5, 2008

Nursing interruptions in a trauma intensive care unit: a prospective observational study.

May 3, 2017

Legal and policy interventions to improve patient safety.

March 2, 2016

Disclosure of harmful medical errors in out-of-hospital care.

August 29, 2012

Targeting improvements in patient safety at a large academic center: an institutional handoff curriculum for graduate medical education.

September 17, 2014

Greatest impact of safe harbor rule may be to improve patient safety, not reduce liability claims paid by physicians.

January 29, 2014

Excess cost and length of stay associated with voluntary patient safety event reports in hospitals.

January 28, 2009

"Health courts" and accountability for patient safety.

September 13, 2006

Beyond negligence: avoidability and medical injury compensation.

October 31, 2007

Systematic root cause analysis of adverse drug events in a tertiary referral hospital.

March 27, 2005

Doing well by doing good: assessing the cost savings of an intervention to reduce central line-associated bloodstream infections in a Hawaii hospital.

June 12, 2013

Resident and RN perceptions of the impact of a medical emergency team on education and patient safety in an academic medical center.

December 2, 2009

Screening for medication errors using an outlier detection system.

February 8, 2017

An examination of medical malpractice claims involving physician trainees.

August 19, 2020

A structured judgement method to enhance mortality case note review: development and evaluation.

December 4, 2013

Malpractice claims related to diagnostic errors in the hospital.

August 23, 2017

Safety culture in the operating room: variability among perioperative healthcare workers.

September 13, 2017

Innovative use of the electronic health record to support harm reduction efforts.

May 24, 2017

Evaluating inpatient mortality: a new electronic review process that gathers information from front-line providers.

November 5, 2014

A survey of factors affecting clinician acceptance of clinical decision support.

February 22, 2006

Does full disclosure of medical errors affect malpractice liability? The jury is still out.

March 6, 2005

Related Resources

National Action Alliance to Advance Patient and Workforce Safety Webinar Series.

September 26, 2023 - September 26, 2023

Patient Safety Innovations

Patient and Family Centered I-PASS (Family-Centered Communication Program to Reduce Medical Errors and Improve Family Experience and Communication Processes)

January 31, 2024

Challenge Competition: Impact of Patient Safety Tools.

December 12, 2023

Patient safety: listen to whistleblowers.

September 27, 2023

Global Knowledge Sharing Platform for Patient Safety.

September 20, 2023

Disclosing medical errors: prioritising the needs of patients and families.

July 5, 2023

Measurement and Monitoring of Safety Framework (MMSF): learning from its implementation in Canada.

June 28, 2023

Racial, Ethnic, and Payer Disparities in Adverse Safety Events: Are there Differences across Leapfrog Hospital Safety Grades?

June 21, 2023

Context matters: toward a multilevel perspective on context in clinical reasoning and error.

June 21, 2023

Patient Safety Innovations

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

May 31, 2023

Patient Safety Primers

Strategies to Improve Organizational Health Literacy.

May 31, 2023

Patient Safety Innovations

Preventing Falls Through Patient and Family Engagement to Create Customized Prevention Plans

May 31, 2023

The Patient Safety Adoption Framework: a practical framework to bridge the know-do gap.

May 31, 2023

VHA's movement for change: implementing high-reliability principles and practices.

May 31, 2023

Medical errors kill thousands of people each year. But are hospitals getting any safer?

May 17, 2023

Towards a unified model of accident causation: refining and validating the systems thinking safety tenets.

May 10, 2023

Individual characteristics that promote or prevent psychological safety and error reporting in healthcare: a systematic review.

May 10, 2023

VA pauses $16B Oracle Cerner EHR deployments indefinitely to address error-ridden early rollout.

May 3, 2023

Roadmap to Health Care Safety for Massachusetts.

May 3, 2023

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

Using a learning system approach to improve safety for prone-position ventilation patients.

April 26, 2023

Patient Safety Primers

Patient Safety Indicators.

April 26, 2023

Racism and electronic health records (EHRs): perspectives for research and practice.

April 12, 2023

An examination of Leapfrog safety measures and Magnet designation.

April 5, 2023

CHaMP: A model for building a center to support health care worker well-being after experiencing an adverse event.

April 5, 2023

Effect of patient safety education interventions on patient safety culture of health care professionals: systematic review and meta-analysis.

March 29, 2023

Quality and safety: learning from the past and (re)imagining the future.

March 29, 2023

Now is the time to routinely ask patients about safety.

March 15, 2023

A multi-site assessment of inpatient safety event rates during the coronavirus disease 2019 pandemic.

January 18, 2023

Interventions into reliability-seeking health care organizations: a systematic review of their goals and measuring methods.

November 30, 2022

See More About The Topic

Hospitals

Ambulatory Clinic or Office

Health Care Executives and Administrators

Quality and Safety Professionals

Medicine

Events that inspired change: the importance of sharing what happened to stop it from happening again.

Patient and Family Centered I-PASS (Family-Centered Communication Program to Reduce Medical Errors and Improve Family Experience and Communication Processes)

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

Strategies to Improve Organizational Health Literacy.

Preventing Falls Through Patient and Family Engagement to Create Customized Prevention Plans

Patient Safety Indicators.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Events that inspired change: the importance of sharing what happened to stop it from happening again.

Patient and Family Centered I-PASS (Family-Centered Communication Program to Reduce Medical Errors and Improve Family Experience and Communication Processes)

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

Strategies to Improve Organizational Health Literacy.

Preventing Falls Through Patient and Family Engagement to Create Customized Prevention Plans

Patient Safety Indicators.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site