Narrow Results Clear All
- WebM&M Cases 1
- Commentary 10
- Review 1
- Study 18
- Audiovisual 2
- Book/Report 9
- Legislation/Regulation 1
- Newspaper/Magazine Article 17
- Newsletter/Journal 1
- Toolkit 3
- Web Resource 18
- Press Release/Announcement 2
- Communication Improvement 34
- Culture of Safety 5
Education and Training
- Students 1
Error Reporting and Analysis
- Error Reporting 26
- Human Factors Engineering 6
- Legal and Policy Approaches 5
- Logistical Approaches 2
- Quality Improvement Strategies 13
- Research Directions 1
- Specialization of Care 2
- Teamwork 4
- Clinical Information Systems 3
- Transparency and Accountability 1
- Device-related Complications 2
- Diagnostic Errors 2
- Discontinuities, Gaps, and Hand-Off Problems 6
- Fatigue and Sleep Deprivation 1
- Identification Errors 3
- Medical Complications 5
- Medication Errors/Preventable Adverse Drug Events 11
- Nonsurgical Procedural Complications 1
- Psychological and Social Complications 5
- Surgical Complications 5
- Internal Medicine 9
- Surgery 4
- Nursing 2
- Palliative Care 1
- Pharmacy 6
- Family Members and Caregivers 12
- Health Care Executives and Administrators
Health Care Providers
- Nurses 9
- Physicians 10
Non-Health Care Professionals
- Media 6
- Australia and New Zealand 3
- Europe 10
- Canada 3
- United States of America 58
Search results for ""
Cases & Commentaries
- Web M&M
Dean Schillinger, MD; March 2004
A misunderstanding of instructions on how to administer medication leads to an infant choking on a syringe cap.
Web Resource > Multi-use Website
P.O. Box 1010, Salt Lake City, UT 84114-1010.
Utah established a number of collaborative initiatives to understand the nature and occurrence of adverse events and implement interventions to reduce their incidence. This site provides access to an adverse drug event (ADE) reporting tool, state administrative rules related to safety, a national patient safety program funded by the Agency for Healthcare Research and Quality (AHRQ), and a complaints mechanism for consumers.
Web Resource > Multi-use Website
Minnesota Hospital and Healthcare Partnership.
The Minnesota Alliance for Patient Safety (MAPS) is a partnership among the Minnesota Hospital Association, Minnesota Medical Association, Minnesota Department of Health, and more than 50 other public-private health care organizations to improve patient safety. Site highlights include information on their "Patients as Partners" campaign.
Web Resource > Multi-use Website
ECRI. Plymouth Meeting, PA.
ECRI is a nonprofit health services research agency. Their mission involves improving the safety, quality, and cost-effectiveness of health care. ECRI focuses on health care technology, health care risk and quality management, and health care environmental management. This site provides free access to some of ECRI's patient safety content.
Middleton, MA: HealthLeaders Media. ISSN: 1553-6637.
Beginning with its inaugural issue in August 2004, Patient Safety and Quality Healthcare (PSQH) is published bi-monthly. News from the field and articles by industry experts round out the content. PSQH seeks to inform patients, clinicians, patient safety officers, risk managers, business leaders, policy makers, educators, and commercial vendors working in all health care settings.
Journal Article > Commentary
Delbanco T, Berwick DM, Boufford JI, et al. Health Expect. 2001;4:144-150.
This viewpoint presents a summary of recommendations from the 1998 Salzburg Seminar entitled “Through the Patient’s Eyes.” The purpose of this seminar series is to offer a neutral forum for discussing beliefs on a variety of topics. The 5-day seminar was attended by 64 individuals from 29 different countries with a mission to create a health care system for a mythical republic called PeoplePower. The premise builds on a principle of “nothing about me without me,” as teams of health professionals, patient advocates, artists, reporters, and social scientists established a conceptual model. The authors share the participants’ visions of an ideal clinician-patient relationship and the role hospitals, national and local governmental agencies, and communities play in supporting such a model. Although they conclude that their health care system remains detached from financial, historical, and societal restraints, the principles serve as reminders that health programs must draw closer together patients and those who care for them.
Web Resource > Government Resource
Centers for Medicare & Medicaid Services.
This Web site features resources to support the Medicare Quality Improvement Program and Medicare Quality Improvement Organizations (QIOs) in delivering quality care.
Weber T, Ornstein C. Los Angeles Times. April 12, 2005.
This article reports on a death that occurred at the Martin Luther King Jr./Drew Medical Center after a patient's deteriorating vitals signs went unnoticed.
Journal Article > Study
Competition and health plan performance: evidence from health maintenance organization insurance markets.
Scanlon DP, Swaminathan S, Chernew M, Bost JE, Shevock J. Med Care. 2005;43:338-346.
This study of 341 health maintenance organizations found that plans in markets with greater competition showed inferior performance on three of six standard quality measures. While the cross-sectional design does not permit causal inferences, these findings argue against the frequently encountered view that greater competition will foster improvements in safety and quality of care.
Scanning out medication errors: Ohio Valley Hospital's automated IV system provides real-time access to patient data.
Carbasho T. Pittsburgh Business Times. April 25, 2005.
This article reports on Ohio Valley General Hospital's intravenous safety system. Using bar code scanning to provide important patient information, the system automates checks for intravenous medication administration.
Dobbs D. New York Times Magazine. April 24, 2005;sect 6:40.
The author interviews experts who discuss the autopsy as a unique method for discovering medical mistakes and why it is not used more often as a teaching and improvement mechanism.
Bull G. USA Today. April 28, 2005.
This article reports on Target pharmacies' redesign of prescription bottles. The new bottles, designed to support safer outpatient medication use, have a flattened label and are color-coded for each family member.
Hospital-error oversight called lax: state takes too long to investigate mistakes, patient advocates say.
Galloway A. Seattle Post-Intelligencer. May 5, 2005.
This article explores inefficiencies in the process for reporting and investigating adverse events in Washington and indicates that inconsistent error review is a problem across the nation.
Weise E. USA Today. May 18, 2005.
Briefings on Patient Safety. June 2005;6:1-3.
This article describes the Partnering for Patient Empowerment Through Community Awareness program, a model for utilizing libraries to educate consumers about their role in patient safety. Pointers for launching similar programs in other communities are provided.
Youngberg BJ, ed. Jones & Bartlett Learning: Sudbuery MA; 2013. ISBN: 9780763774042.
This revised edition of a comprehensive resource on patient safety includes new chapters discussing such topics as the complexity of defining error and the need for medical and nursing education to develop leadership skills to help drive improvement efforts.
Brooks A. New York Times. June 14, 2005:F5.
This article provides a brief review of safety concerns associated with free-standing surgical centers.
Kerber R. The Boston Globe. June 23, 2005;Business section:E1.
This article reports on problems with medical devices and discusses whether manufacturers should directly notify patients regarding defects.
Scobie S, Thomson R. London, England: National Patient Safety Agency; 2005.
Created in 2001 to institute changes in health care across the United Kingdom, the National Patient Safety Agency (NPSA) presents their first report of patient safety incidents. The two-part report begins with a general discussion of incident reporting, the basis for a national reporting system, and the development of the Patient Safety Observatory. The second part builds on this framework by discussing how the acquired data can be used and translated into safer health care strategies. The report itself encompasses more than 85,000 collected incident reports with analysis, comparisons, and case studies to illustrate important safety issues for future efforts. This represents the first of a series of expected reports from NPSA on patient safety data to be published.
Kowalczyk L. The Boston Globe. July 24, 2005.
This article reports on a proposed disclosure policy among Harvard Medical School teaching hospitals. The policy would outline a process for discussing error with patients and for training physicians on how to apologize.