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1 - 14 of 14

Cleghorn E. New York, NY: Dutton; 2021. ISBN: 9780593182956.

Women have been affected by implicit bias that undermines the safety of their care and trust in the medical system. This book shares the history anchoring the mindsets driving ineffective care for women and a discussion of the author’s long-term lupus misdiagnosis.

Washington, DC: Department of Veterans Affairs, Office of Inspector General; November 17, 2020. Report No 19-08542-11.

Incomplete assessment of patient needs can miss opportunities to prevent patient harm. This report analyzes an incident where an intoxicated patient called a dedicated crisis support line yet preventive measures weren’t activated to avert an accidental overdose resulting in patient death. Recommendations for improvement include enhanced training for weekend and holiday staff, standardized safety plan development, and systemized internal review processes.

Sinsky CA, Biddison LD, Mallick A, et al. NAM Perspectives. Washington DC: National Academy of Medicine; 2020.

Clinician well-being is determined by system characteristics that support patient safety. This perspective suggests six areas of organizational focus to improve clinician well-being and resiliency including assessment, leadership, and support mechanisms.

Herd P, Moynihan D. Health Affairs Health Policy Brief. October 2, 2020.

The crossover of health equity concepts to patient safety has emerged as a consideration for improvement. This policy brief examines how administrative burdens can separate patients from the care they need and calls for increased attention to the problem.  

Auraaen A, Saar K, Klazinga N for the Organisation for Economic Co-operation and Development. OECD Publishing, Paris, France; 2020. OECD Health Working Papers, No. 120.

Policies, laws, and guidelines aid organizations to develop, prioritize and achieve patient safety goals. This report examined a 25-country analysis of patient safety governance efforts and found that learning and non-punitive approaches are strategies being progressively implemented worldwide.

London, UK: The Parliamentary and Health Service Ombudsman; July 15, 2020. ISBN 9781528620666.

Patient and family complaints can provide insights into system weaknesses if managed effectively. This report examined complaint handling at the United Kingdom National Health Service. The analysis found that lack of training, consistency and learning orientation reduced the effectiveness of the effort.

Washington, DC: Department of Veterans Affairs, Office of Inspector General; September 3, 2020. Report No 19-09493-249.

Discontinuities in mental health care are a patient safety concern. This report analyzes how documentation gaps, medication reconciliation problems, and poor care coordination contributed to the suicide of a patient who presented at an emergency room, was screened there, and referred to a clinic for further care that was not completed.

Farnborough, UK; Healthcare Safety Investigation Branch: April 2019.

Wrong route medication administration is a never event. This report examined the context, organizational and human factors that contributed to the accidental intravenous administration of an oral solution into a pediatric patient. Safety recommendations include medication safety training, standardized administration processes, and elevation of the medication safety officer role. 
Hewitt M, Hernandez LM; Roundtable on Health Literacy, Board on Population Health and Public Health Practice, Institute of Medicine. Washington, DC: National Academies Press; 2014. ISBN: 9780309303651.
Health literacy can affect patients' ability to understand directions, ask good questions, and participate in care. Framing health literacy as a public health challenge, this report describes efforts to address it in three states and explores implementation and research to improve it across the United States.

Dalton D, Williams N. London, UK: The Royal College of Surgeons of England; March 2014. 

When medical errors occur, patients desire full disclosure. This report calls for clinicians in the National Health Service to disclose errors that contribute to moderate or severe harm or death. The authors outline recommendations to help organizations establish a safety culture that requires discussion about unanticipated events and ensures that staff receive training in apologies.

Roundtable on Joy and Meaning in Work and Workforce Safety, The Lucian Leape Institute. Boston, MA: National Patient Safety Foundation; 2013.

The Lucian Leape Institute hosted two roundtables and multiple focus groups to explore the need to create safer working conditions for health care professionals. This report highlights the current state of health care workplaces, which subject many health care workers to emotional and physical harms in the course of providing care. The authors also explicitly link workplace safety to patient safety, noting that poor working conditions place caregivers at higher risks for making medical errors. The report outlines seven strategies for organizations to improve workplace safety, challenging health care centers to become effective high-reliability organizations that are committed to continuous learning, improvement, teamwork, and transparency. An AHRQ interview with Dr. Lucian Leape describes his remarkable career at the forefront of the patient safety movement.
Boston, MA: Massachusetts Coalition for the Prevention of Medical Errors; 2006.
This consensus paper of the Harvard-affiliated hospitals was prepared by clinicians, risk managers, and patients to provide an in-depth understanding of preventable adverse events, their impact on patients, families, and providers, and how to manage such events. The report provides detailed guidelines based on the premise that all care should be safe and patient-centered and that all actions require full disclosure. In addition to offering recommendations on how to effectively communicate with patients and families, the report discusses support for caregivers and a detailed strategy for institutions to respond to such events in a timely and appropriate fashion. Finally, the comprehensive report offers several appendices that include recommendations and a case study on communicating with patients and families.

Smedley BD, Stith AY, Nelson AR, eds and Institute of Medicine. Washington, DC; The National Academies Press: 2003. ISBN 9780309082655.

Patient race and socioeconomic disparities result in biases that affect patient safety. This publication examines strategies to minimize these impacts such as interpreter use, localized care delivery, and improved data collection to better ascertain the true state of the problem and design initiatives to address it.