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Leapfrog Group.
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. 

Farnborough, UK: Healthcare Safety Investigation Branch; September 24, 2020. 

Unit-based pharmacy services help to mitigate and catch medication errors. This report highlights a case of a medication error death and describes how embedding clinical pharmacy services could have prevented this incident. The report provides system level recommendations to enhance this service including defining the role of clinical pharmacy teams and prioritizing the tactic as an important improvement strategy.   

NHS Improvement. Independent Mortality Review of Cardiac Surgery at St George’s University Hospitals NHS Foundation Trust. NHS England. March 2020.

In-depth incident investigations provide details of care process examinations to motivate learning and improvement. This report examines cardiac surgery patient mortality at a National Health Service Trust over a 5-year period. It highlights weakness in professionalism at the individual and organization level as a contributor to the preventable patient deaths catalogued over that time.

Working Group on Medication Overload. Brookline, MA: Lown Institute; 2020.

Polypharmacy and medication overuse are known contributors to patient harm. This report outlines recommendations for combating medication overload. The recommendations include prescription review, issue awareness, point-of-care information access, training and industry influence reduction as tactics for improvement.

Holmes A, Long A, Wyant B, et al. Rockville, MD: Agency for Healthcare Research and Quality; March 2020. AHRQ Publication No. 20-0029-EF.

This newly issued follow up to the seminal AHRQ Making Health Care Safer report (first published in 2001 and updated in 2013 critically examines the evidence supporting 47 separate patient safety practices chosen for the high-impact harms they address. It includes diagnostic errors, failure to rescue, sepsis, infections due to multi-drug resistant organisms, adverse drug events and nursing-sensitive conditions. The report discusses the evidence on cross-cutting safety practices, including safety culture, teamwork and team training, clinical decision support, patient and family engagement, cultural competency, staff education and training, and monitoring, audit and feedback. The report provides recommendations for clinicians and decision-makers on effective patient safety practices.
Lim R, Semple S, Ellett LK, Roughead L. Canberra, Australia: Pharmaceutical Society of Australia; 2019.
Analyzing the evidence on medication errors in Australia, this report estimates the incidence of acute care admissions, emergency department use, ambulatory adverse events, and elderly patients affected by medication-related problems. Pharmacists are emphasized as pivotal to medication safety improvement efforts.
The British Diabetic Association; Diabetes UK.
Chronic disease management can add complexity to inpatient care regimens. Researchers worked with patients, system leaders, and clinicians to examine areas of risk for hospitalized patients with diabetes and determine solutions such as specialized teams, clinical leadership, and improved use of technology. A WebM&M commentary illustrated safety challenges associated with providing care for hospitalized patients with diabetes.
Horsham, PA: Institute for Safe Medication Practices; 2018.
Medication safety is a concern in various settings across an organization. This white paper discusses the role of a medication safety officer to oversee reporting and analysis of medication errors and coordinate improvement efforts. Responsibilities of a medication officer include serving as a champion, advocating for safety interventions, and helping implement system changes.

Tully MP, Franklin BD, eds. Boca Raton, FL: CRC Press, Taylor and Francis Group; 2016. ISBN: 9781482227000.

Errors in the prescription, preparation, and administration of medications hinder safe patient care. This book summarizes theories and international practices to provide clinical pharmacists with strategies to address barriers to medication safety.
Agency for Healthcare Research and Quality. Health Care Innovations Exchange. May 18, 2016.
This issue highlights innovations that can be applied in a variety of health care environments to prevent hospital-acquired conditions. The resources include the Chartbook on Patient Safety and checklist, decision support, and screening programs.
Rockville, MD: Agency for Healthcare Research and Quality; July 2013. AHRQ Publication No. 13-0071-EF.
This report provides preliminary outcome data from a six-cohort collaborative that used the comprehensive unit-based safety program and associated tools to prevent catheter-associated urinary tract infections (CAUTI). The early data show a decrease in the overall rate of CAUTI, with a more striking decrease in non-intensive care unit settings than in ICU settings.
Rockville, MD: Agency for Healthcare Research and Quality; September 2011. AHRQ Publication No. 11-0037-1-EF.
This publication reports the impact hospital participation in CUSP had on patients. This AHRQ-funded program was designed to reduce central line infections using concepts tested in the successful Keystone program.

Dornan T, Ashcroft D, Heathfield H, et al. London: General Medical Council; 2009.

This report analyzed the causes and rates of prescribing errors in the National Health Service and found that educational level had little impact on medication errors and that many were intercepted before reaching patients. The authors suggest that a standardized national prescription chart could help prevent errors.
Scheurer D, ed. Oakbrook Terrace, IL: Joint Commission Resources; 2009. ISBN: 9781599403045.
This book discusses the rise of the hospitalist movement within the context of quality and safety and reviews how hospitalists can support several National Patient Safety Goals.