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- Communication Improvement
- Culture of Safety 1
- Education and Training 2
- Error Reporting and Analysis 5
- Human Factors Engineering 1
- Device-related Complications 1
- Discontinuities, Gaps, and Hand-Off Problems 1
- Identification Errors 1
- Medical Complications 1
- Medication Safety 3
- Psychological and Social Complications 1
- Surgical Complications 2
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Fifty-first Report of Session 2005-06. House of Commons Committee on Public Accounts. London, England: The Stationary Office; July 6, 2006. Publication HC 831.
Health care work environments, employee satisfaction, and patient safety: care provider perspectives.
Rathert C, May DR. Health Care Manage Rev. 2007;32:2-11.
The authors sought to measure the relationship between nurse perception of patient-centeredness in their unit and its effect on safety. They found that nurses in an patient-centered environment were more satisfied with their jobs and more comfortable discussing and reporting errors.
Journal Article > Study
Do medical inpatients who report poor service quality experience more adverse events and medical errors?
Taylor BB, Marcantonio ER, Pagovich O, et al. Med Care. 2008;46:224-228.
Prior research has demonstrated that problems with service quality—for example, waits and delays, poor communication, and poor amenities—are common in hospitals. While patients tend to identify these issues when surveyed about problems they perceive with the quality of care they receive, no relationship has yet been identified between service quality and patient safety. This AHRQ-funded study used retrospective chart review to correlate patients' complaints of poor service quality with documented adverse events and found that patient-reported instances of poor service quality were associated with double the risk of medical errors. The authors hypothesize that some factors associated with the quality of medical care, such as communication between team members, may also be reflected in service quality.
Grant T. Washington Post. July 22, 2008:HE01
This article reports on a wrong-sided surgery near miss from the perspective of a parent, and discusses the role of family members in preventing medical errors.
McCook A. Anesthesiology News. Sept 2011;37:9.
This news article highlights a program at Johns Hopkins Medicine that engages clinician reporting of errors and near misses to improve patient safety.
Connor M, Wayman KI, Garcia C, Fischer PR; Consortium for Maximizing Family-Centered Care. Patient Saf Qual Healthc. September/October 2014;11:36,38-40,42.
Patients are increasingly encouraged to take an active role in their own safety during hospital care. Describing a near miss of a medication error, this magazine article examines elements of effective disclosure and how engaging patients and their families can contribute to error investigations and safety improvement.