Narrow Results Clear All
- Communication Improvement 4
- Education and Training 2
- Error Reporting and Analysis 3
- Human Factors Engineering 1
- Legal and Policy Approaches 2
- Logistical Approaches 1
- Quality Improvement Strategies 2
- Technologic Approaches 2
- Discontinuities, Gaps, and Hand-Off Problems 2
- Identification Errors
- Medical Complications 2
- Medication Safety 4
- Surgical Complications 3
Search results for "Web Resource"
St. Paul, MN: Minnesota Department of Health; March 2019.
The National Quality Forum has defined 29 never events—patient safety problems that should never occur, such as wrong-site surgery and patient falls. Since 2003, Minnesota hospitals have been required to report such incidents. The 2018 report summarizes information about 384 adverse events that were reported and found pressure ulcers and invasive procedure events increased, while fall-related deaths decreased. Reports from previous years are also available.
Legislation/Regulation > Government Resource
Safe Practice Notice 24. London, England: National Patient Safety Agency; July 3, 2007.
This notice highlights the importance of standardizing wristband design and information to make their use consistent for every patient in the United Kingdom.
Paterson R. Auckland, New Zealand: Office of the Health and Disability Commissioner; April 24, 2007.
This report analyzes an incident of medication error that led to a patient's death, discusses the subsequent actions taken by the health board, and calls for a coordinated approach to medication reconciliation in New Zealand.
Kowalczyk L. Boston Globe. April 21, 2007:B1.
This article reports on the results from Joint Commission site inspections of five Boston-area hospitals.
East Perth, WA, Australia: Department of Health of Western Australia; 2006.
This report shares the 2005-2006 results of Western Australia's sentinel event reporting program and documents a reduction in two types of events: wrong site/wrong part surgeries and retained foreign objects.
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.
Web Resource > Multi-use Website
Oakbrook Terrace, IL: Joint Commission.
This campaign provides sets of materials to enable patients and families to engage in making their health care experiences as safe as possible. Topics covered include safe surgery, pain management, medication safety, and most recently, infection prevention. Each topical package includes infographics, videos, instruction guides, and a podcast.
Legislation/Regulation > Multi-use Website
The Joint Commission.
According to an AHRQ-supported study, wrong-site surgery occurred at a rate of approximately 1 per 113,000 operations between 1985 and 2004. In July 2004, The Joint Commission enacted a Universal Protocol that was developed through expert consensus on principles and steps for preventing wrong-site, wrong-procedure, and wrong-person surgery. The Universal Protocol applies to all accredited hospitals, ambulatory care, and office-based surgery facilities. The protocol requires performing a time out prior to beginning surgery, a practice that has been shown to improve teamwork and decrease the overall risk of wrong-site surgery. This Web site includes a number of resources and facts related to the Universal Protocol. Wrong-site, wrong-procedure, and wrong-patient errors are all now considered never events by the National Quality Forum and sentinel events by The Joint Commission. The Centers for Medicare and Medicaid Services have not reimbursed for any costs associated with these surgical errors since 2009.
Tools/Toolkit > Fact Sheet/FAQs
Rockville, MD: Agency for Healthcare Research and Quality; October 2001. AHRQ Publication No. 01-0017.
A brief presentation of "pearls" to allow consumers to take an active role in preventing medical errors.