All Content

Maternal care during and after childbirth is at risk for never events including retained foreign objects. This analysis of a sentinel event involving a retained surgical tampon after childbirth discusses communication, fatigue, and process factors that contributed to the incident. The report suggests improved handoffs as one improvement strategy.

This toolkit provides information for hospitals to help reduce preventable readmissions among Medicaid patients. Building on hospital experience with utilizing the materials since 2014, this updated guide explains how to determine root causes for readmissions, evaluate existing interventions, develop a set of improvement strategies, and optimize care transition processes.

Patient safety in ambulatory care is receiving increased attention. This guide includes case studies that explore how Open Notes, team-based care delivery, and patient and family advisory committees have shown promise as patient engagement and safety improvement mechanisms in primary care settings.

Misrepresentation of findings, either by accident or design, can result in ineffective use of resources and poor decision-making. This investigation found inconsistencies in the information reported by the Veterans Health Administration in the widely-publicized analysis discussing weaknesses in the organization that resulted in delayed care. The author calls for the assessment to be revisited to ensure conclusions and work toward improvement are verifiable to augment the safety and timeliness of care provided to veterans.

This report analyzes the literature discussing emergency department discharge processes and highlights elements of high-quality discharges and risk factors for suboptimal discharges. The in-depth review summarizes interventions currently implemented to augment discharge procedures, care coordination, and the identification of patients more susceptible to poor discharge.

This investigation outlines how inadequate care contributed to the death of a child who developed sepsis while receiving treatment for the flu. Describing failures associated with telephone triage and out-of-hours service in the course of his care, the report recommends organization-wide efforts to improve safety, including providing guidelines for staff and support or families.

This report proposes five responsibilities for ambulatory care practices to ensure safe care transitions and describes principles to guide staff in performing these tasks.

This series, developed in conjunction with the STAAR initiative, provides tactics and resources to improve transitions across various care settings.

Consumers' perceptions of health care quality and access to information about quality have changed little since the 2006 version of this survey. Coordination of care among providers was a major concern for survey respondents, with two-thirds of those surveyed feeling that care coordination was at least a minor problem, and 22% reporting having visited a clinician who did not have access to all of their health information (including test results). Despite the growing focus on making health care quality information transparent and accessible to consumers, few respondents reported accessing information about the quality of their health plan, physician, or hospital, and even fewer reported using such information to make decisions about their care.

The quality of care delivered at US hospitals continues to improve, according to data gathered by the Joint Commission from nearly 1,500 institutions. Hospitals improved their provision of evidence-based care for patients with heart attacks, congestive heart failure, and pneumonia, and also improved at prevention of health care–associated infections in surgical patients. As in the 2007 report, adherence to the National Patient Safety Goals was more mixed. Although performance improved in some areas (including medication reconciliation and eliminating "do not use" abbreviations), many hospitals do not systematically perform time outs prior to procedures, or have reliable mechanisms for communicating critical test results.

This report compiles public and private data to provide insight into the quality and safety of patient care in Australian hospitals.

This report analyzes the findings of a diagnostic error investigation and provides numerous recommendations to improve standards for treating symptomatic breast disease.

In analyzing information submitted to the British voluntary incident reporting system, this report revealed safety problems that contributed to delays in treatment and resuscitation.

Low health literacy is a recognized patient safety problem. Prior research has demonstrated that patients with impaired health literacy have difficulty comprehending prescription instructions and warnings. This Joint Commission report, developed by an expert panel, contains specific recommendations for improving provider–patient communication, in order to ameliorate the problem of low health literacy as much as possible. The report recommends that organizations establish communication as a patient safety priority and calls for financial support for patient-centered care initiatives.

In the 2003 report Safe Practices for Better Healthcare, the National Quality Forum (NQF) recommended 30 practices, one of which emphasized improved communication in the informed consent process. This report builds on that safe practice endorsement by summarizing strategies for rapid and widespread adoption. The report describes experiences from four hospitals that successfully implemented the practice and discusses common barriers and solutions involved. Recommendations are provided to guide health care organizations still striving to meet the requirement for an effective informed consent process.

This report outlines 10 guiding principles to support medication management as patients transfer from one care environment to another.

A workbook that presents a series of self-learning modules introducing concepts of complexity science.