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This website offers resources related to the Leapfrog Hospital Survey investigating hospitals' progress in implementing specific patient safety practices. Updates to the survey include increased time allotted to complete computerized provider order entry evaluation, staffing of critical care physicians on intensive care units, and use of tools to measure safety culture. Reports discussing the results are segmented into specific areas of focus such as health care-associated infections and medication errors. 

Drawing from data reported by the Leapfrog Hospital Survey, the Agency for Healthcare Research and Quality (AHRQ), the Centers for Disease Control and Prevention (CDC), and the Centers for Medicare and Medicaid Services (CMS), this website provides grades for hospitals in the United States based on their safety. The Spring 2022 hospital safety grade results are available. A 2019 report from the Armstrong Institute examines avoidable death associated with grading hospitals. 

Maternal harm during and after pregnancy is a sentinel event. This campaign encourages women, families, and health providers to identify and speak up with concerns about maternal care and act on them. The program seeks to inform the design of support systems and tool development that enhance maternal safety.

Patient safety improvement has made progress but more can be done. This organization supports community efforts in the United States to engage policymakers in work toward aligning efforts to reduce preventable patient harm at a national level. It will build its efforts on the World Health Organization plan by moving forward with a framework to collaborate on a variety of strategies to enhance the safety of health care.

In this annual publication, AHRQ reviews the results of the National Healthcare Quality Report and National Healthcare Disparities Report. This 2021 report highlights that a wide range of quality measures have shown improvement in quality, access, and cost.

Removing unused medications from the home can help prevent accidental exposure to unneeded medications and limit their availability for misuse. This annual program provides patients with an opportunity to discard medications safely. The sponsors also provide education to highlight the importance of appropriate disposal of unused prescription drugs as a medication safety activity.

Errors of commission during complex procedures can contribute to patient harm. Drawing from an analysis of medical device reports submitted to the Food and Drug Administration, this updated announcement seeks to raise awareness of common adverse events associated with surgical staplers and implantable staples. User-related problems include opening of the staple line, misapplied staples, and staple gun difficulties. Recommendations include ensuring availability of various staple sizes and avoiding use of staples on large blood vessels.

This announcement seeks to raise awareness of the potential risks associated with the use of robotic-assisted surgical devices in mastectomies or cancer-related care. Recommendations for patients who may seek to have robotically assisted surgery include asking about their surgeon's experience with these procedures and discussing benefits, risks, and alternatives regarding available treatment options with their health care provider. Suggestions for health care providers include completing specialized training on procedures they perform. A WebM&M commentary described the challenges and benefits associated with robotic surgery.

To protect children and pets from accidental exposure to prescription medications, this consumer alert outlines the dangers of inappropriate storage and disposal of medication skin patches.

The Centers for Medicare and Medicaid Services (CMS) provides consumers with publicly available information on the quality of Medicare-certified hospital care through this Web site. The site includes specific information for both patients and hospitals on how to use the data to guide decision-making and improvement initiatives. Most recently, listings from the Hospital-Acquired Condition Reduction Program (HACRP) and data on Department of Veterans Affairs hospitals were added to the reports available.

Never events provide organizations with motivation to analyze and learn from errors due to their catastrophic nature. This National Learning Report provides a thematic examination of never events in the National Health Service (NHS). The report found misattribution of incidents as never events in the NHS due to lack of systemic factors as contributors to those events. A revision of the NHS never events list is recommended. 

Misdiagnosis can perpetuate over a long period and delay a correct course of treatment. This news feature shares an example of depression misdiagnosis that masked the true problem of a neurological tumor manifesting in what was seen and treated as a psychological condition. 

Patients and families experiencing medical error may not always have access to the support needed to navigate the system to inform improvements and receive appropriate restitution. This hotline will provide general information to individuals that contact the organization for help when they feel an error may have occurred in their care or the care of a family member. 

Physicians have unique perspectives when exposed to health care delivery problems as patients themselves or as caregivers. This news story shares the author’s frustrations with the system of care observed during an overnight visit at the bedside of her daughter awaiting an emergency appendectomy. Her experience underscored the value of patients and families engaging in the safety of actions clinicians take when providing care. 

Uncertainty, misinformation, management gaps, and rapid escalation undermine crisis response effectiveness. This article illustrates system, leadership, and process failures that contributed to harms associated with the COVID-19 pandemic. 

This annual report compiles patient safety data documented by Massachusetts hospitals. The 2019 numbers represent a modest increase in serious reportable events recorded in acute care hospitals, from 1066 the previous year to 1189. This presentation also includes events from ambulatory surgery centers. Previous years reports are also available.

Insulin use errors are common despite their heightened potential for patient harm. This announcement highlights labeling and storage practices to reduce dispensing and administration errors associated with individual insulin pen use.    

Implicit and explicit biases affect many facets of the health care delivery system. This story shares African-American patient experiences with bias that reduced the safety of maternity care.