National Patient Safety Agency: combining stories with statistics to minimise harm.

Tara Lamont; John Scarpello

Study

National Patient Safety Agency: combining stories with statistics to minimise harm.

December 2, 2009

Lamont T, Scarpello J. BMJ. 2009;339:b4489.

View more articles from the same authors.

This news item discusses "rapid response reports," a National Patient Safety Agency initiative to alert practitioners about reported patient safety incidents.

PubMed citation

Available at

Related Resources From the Same Author(s)

Safety in Doses.

September 16, 2009

Review of Patient Safety for Children and Young People.

July 1, 2009

Organisation Patient Safety Incident Reports.

April 27, 2011

Safe Foundations: Junior Doctors and Patient Safety.

September 20, 2006

Patient Safety 2006.

December 7, 2005

Being open: communicating patient safety incidents with patients and their carers.

September 28, 2005

National Patient Safety Agency (NPSA).

March 6, 2005

Medical Error.

September 28, 2005

Safety First: One Year On.

January 9, 2008

Prevalence of potentially harmful multidrug interactions on medication lists of elderly ambulatory patients.

December 22, 2021

Patient safety's missing link: using clinical expertise to recognize, respond to and reduce risks at a population level.

November 25, 2015

Never Events--Framework 2010-11.

March 4, 2010

Operating room to intensive care unit handoffs and the risks of patient harm.

July 22, 2015

A bottom-up approach addressing patient care and differential diagnosis amidst the Covid-19 response.

October 14, 2020

Safety First: a Report for Patients, Clinicians and Healthcare Managers.

January 17, 2007

Standardising wristbands improves patient safety.

August 1, 2007

Building a Memory: Preventing Harm, Reducing Risks and Improving Patient Safety.

August 3, 2005

2014 Guide to State Adverse Event Reporting Systems.

July 8, 2015

Information Design for Patient Safety: A Guide to the Graphic Design of Medication Packaging. 2nd edition.

November 23, 2007

Diagnostic errors, health disparities, and artificial intelligence: a combination for health or harm.

September 1, 2021

Prosocial voice in the hierarchy of healthcare professionals: the role of emotions after harmful patient safety incidents.

March 22, 2023

Getting the whole story: integrating patient complaints and staff reports of unsafe care.

July 28, 2021

The negative impact of nurse-physician disruptive behavior on patient safety: a review of the literature.

September 16, 2009

The husband's story: from tragedy to learning and action.

June 10, 2015

The problem with…using stories as a source of evidence and learning.

March 9, 2022

Joshua’s Story.

December 3, 2014

Hospital Survey on Patient Safety Culture: 2009 Comparative Database Report.

June 10, 2009

The Health Literacy of America's Adults: Results from the 2003 National Assessment of Adult Literacy.

September 20, 2006

Adverse Drug Events in US Hospitals, 2004.

April 25, 2007

With Safety in Mind: Mental Health Services and Patient Safety.

September 6, 2006

A theoretical model of flow disruptions for the anesthesia team during cardiovascular surgery.

September 22, 2021

Combined proactive risk assessment: unifying proactive and reactive risk assessment techniques in health care.

June 29, 2022

Engaging as partners in patient safety: the experience of librarians.

April 8, 2009

Taking Charge of Your Healthcare: Your Path to Being an Empowered Patient.

July 22, 2009

Safer Care for the Acutely Ill Patient: Learning from Serious Incidents.

October 24, 2007

Medication errors in community pharmacies: evaluation of a standardized safety program.

March 15, 2023

Serious Reportable Events

December 15, 2010

Safe Practices for Better Healthcare–2009 Update.

March 18, 2009

Association of opioid consumption profiles after hospitalization with risk of adverse health care events.

June 2, 2021

Characteristics of Weekday and Weekend Hospital Admissions, 2007.

March 17, 2010

April 27, 2011

Understanding the "Swiss cheese model" and its application to patient safety.

July 21, 2021

The patient's "story": an examination of patient-reported safety incidents in general practice.

May 4, 2022

Medical Office Survey on Patient Safety Culture: 2016 User Comparative Database Report.

June 8, 2016

Adult Hospital Stays with Infections Due to Medical Care, 2007.

September 15, 2010

Adverse Drug Events in U.S. Hospitals, 2010 Versus 2014.

March 14, 2018

Trends in Potentially Preventable Inpatient Hospital Admissions and Emergency Department Visits.

May 11, 2016

Origin of Adverse Drug Events in US Hospitals, 2011.

October 9, 2013

Poor medication history plus slow symptom onset delays a diagnosis.

November 4, 2009

Patient safety from executive hospital management to wards: a qualitative study identifying factors influencing implementation.

August 5, 2020

VA Interprofessional Fellowship Program in Patient Safety.

November 22, 2006

National Center for Patient Safety Falls Toolkit 2004.

March 27, 2005

Healthcare Failure Mode and Effect Analysis.

March 6, 2005

National Patient Safety Foundation.

March 27, 2005

The National Patient Safety Foundation Research Program.

March 27, 2005

TIPS (Topics in Patient Safety).

March 27, 2005

Pharmacy Safety and Service—What You Should Expect.

March 6, 2005

Conceptual Framework for the International Classification for Patient Safety Version 1.1. Final Technical Report January 2009.

September 6, 2006

The role of anesthesia in surgical mortality.

March 6, 2005

Medical Office Survey: 2020 User Database Report.

April 28, 2021

From tragedy to advocacy.

September 30, 2009

AHRQ Nursing Home Survey on Patient Safety Culture: 2016 User Comparative Database Report.

November 23, 2016

Hospital Survey on Patient Safety Culture: 2016 User Comparative Database Report.

May 11, 2016

An In Depth Investigation into Causes of Prescribing Errors by Foundation Trainees in Relation to Their Medical Education—EQUIP Study.

January 6, 2010

Better understanding the downsides of low value healthcare could reduce harm.

April 21, 2021

Systems approach to health service design, delivery and improvement: a systematic review and meta-analysis.

February 3, 2021

Inpatient Computerized Provider Order Entry: Findings from the AHRQ Health IT Portfolio.

March 4, 2009

Patient Safety Huddle.

May 24, 2017

Ensuring Correct Surgery.

February 8, 2006

Preventing Infections in the Hospital—What You As a Patient Can Do.

March 27, 2005

Safety as You Go from Hospital to Home.

March 6, 2005

Analysis of results from event investigations in industrial and patient safety contexts.

April 7, 2021

October 3, 2018

Association between hospital acquired harm outcomes and membership in a national patient safety collaborative.

August 10, 2022

Possible net harms of breast cancer screening: updated modelling of Forrest report.

December 21, 2011

The burden of opioid-related mortality in the United States.

July 18, 2018

Up Next for Patient Safety.

June 9, 2023

Mix-up (wrong route of administration) of bladder irrigation with intravenous (IV) infusions.

May 3, 2006

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

December 22, 2021

Preventing overdiagnosis: how to stop harming the healthy.

June 27, 2012

Deaths in Acute Hospitals: Caring to the End?

November 25, 2009

Validity of unplanned admission to an intensive care unit as a measure of patient safety in surgical patients.

December 14, 2005

Indicators for implementation outcome monitoring of reporting and learning systems in hospitals: an underestimated need for patient safety.

May 4, 2022

Transforming Health Care: A Compendium of Reports From the National Patient Safety Foundation's Lucian Leape Institute.

June 1, 2016

RCA2: Improving Root Cause Analyses and Actions to Prevent Harm.

June 24, 2015

Free From Harm: Accelerating Patient Safety Improvement Fifteen Years After To Err Is Human.

December 16, 2015

Reducing Diagnostic Errors.

November 21, 2012

Patient Safety Curriculum.

December 10, 2008

National Agenda for Action: Patients and Families in Patient Safety.

March 6, 2005

January 11, 2017

Resilience vs. vulnerability: psychological safety and reporting of near misses with varying proximity to harm in radiation oncology.

November 18, 2020

AHRQ Health Services Research Projects: Making Health Care Safer in Ambulatory Care Settings and Long Term Care Facilities (R01).

March 4, 2015

Patient safety reporting systems: sustained quality improvement using a multidisciplinary team and "Good Catch" awards.

August 1, 2012

Health information technology-related wrong-patient errors: context is critical.

January 27, 2021

COVID-19 pandemic preparation: using simulation for systems-based learning to prepare the largest healthcare workforce and system in Canada.

September 30, 2020

Health Information Technology through the Lens of Patient Safety.

November 20, 2013

Call to Action: Preventable Health Care Harm Is a Public Health Crisis and Patient Safety Requires a Coordinated Public Health Response.

March 22, 2017

‘I am not the doctor for you’: physicians’ attitudes about caring for people with disabilities.

October 26, 2022

Many well-known hospitals fail to score high in Medicare rankings.

August 10, 2016

People with disabilities fear pandemic will worsen medical biases.

April 29, 2020

Related Resources

Annual Perspective

Equity in Patient Safety

March 27, 2024

Perspective

Patient Safety in Office-Based Care Settings

January 31, 2024

Interview

In Conversation with...Richard Ricciardi about Office-Based Patient Safety

January 31, 2024

MHA and MHA Keystone Center Annual Reports.

October 20, 2023

Health Services Safety Investigations Body.

October 1, 2023

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

Patient Safety Innovations

The I-READI Quality and Safety Framework: Strong Communications Channels and Effective Practices to Rapidly Update and Implement Clinical Protocols During a Time of Crisis

March 15, 2023

Annual Perspective

Patient Safety in the Ambulatory Care Setting

August 5, 2022

Each Baby Counts.

April 1, 2021

Analysis of paediatric long-term ventilation incidents in the community

January 22, 2020

A mixed-methods study of challenges experienced by clinical teams in measuring improvement.

September 11, 2019

Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis.

July 31, 2019

Gosport War Memorial Hospital. The Report of the Gosport Independent Panel.

November 7, 2018

Safer healthcare at home: detecting, correcting and learning from incidents involving infusion devices.

April 18, 2018

Improving surgical complications and patient safety at the nation's largest military hospital: an analysis of National Surgical Quality Improvement Program data.

March 29, 2017

A national physician survey of diagnostic error in paediatrics.

October 26, 2016

PIPc study: development of indicators of potentially inappropriate prescribing in children (PIPc) in primary care using a modified Delphi technique.

September 28, 2016

Impact of initial hospital diagnosis on mortality for acute myocardial infarction: a national cohort study.

September 14, 2016

Deaths following prehospital safety incidents: an analysis of a national database.

April 6, 2016

Safer prescribing—a trial of education, informatics, and financial incentives.

March 30, 2016

What would you ideally do if there were no targets? An ethnographic study of the unintended consequences of top-down governance in two clinical settings.

March 23, 2016

Qualitative evaluation of the Safety and Improvement in Primary Care (SIPC) pilot collaborative in Scotland: perceptions and experiences of participating care teams.

March 16, 2016

The Safer Delivery of Surgical Services Program (S3): explaining its differential effectiveness and exploring implications for improving quality in complex systems.

February 24, 2016

The Healthcare Complaints Analysis Tool: development and reliability testing of a method for service monitoring and organisational learning.

February 24, 2016

Implications of case managers' perceptions and attitude on safety of home-delivered care.

February 17, 2016

The role of emotion in patient safety: are we brave enough to scratch beneath the surface?

January 27, 2016

Medication safety at the interface: evaluating risks associated with discharge prescriptions from mental health hospitals.

January 20, 2016

Association between day of delivery and obstetric outcomes: observational study.

December 9, 2015

What is the role of individual accountability in patient safety? A multi-site ethnographic study.

November 25, 2015

Monitoring patient safety in primary care: an exploratory study using in-depth semistructured interviews.

November 25, 2015

See More About The Topic

Health Care Providers

Health Care Executives and Administrators

Quality Improvement Strategies

Error Reporting and Analysis

National Patient Safety Agency: combining stories with statistics to minimise harm.

The I-READI Quality and Safety Framework: Strong Communications Channels and Effective Practices to Rapidly Update and Implement Clinical Protocols During a Time of Crisis

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

National Patient Safety Agency: combining stories with statistics to minimise harm.

The I-READI Quality and Safety Framework: Strong Communications Channels and Effective Practices to Rapidly Update and Implement Clinical Protocols During a Time of Crisis

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