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- Commentary 18
- Review 6
- Study 43
- Audiovisual 2
- Book/Report 6
- Legislation/Regulation 1
- Newspaper/Magazine Article 23
- Special or Theme Issue 2
- Tools/Toolkit 3
- Web Resource 18
- Award 11
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- Press Release/Announcement 13
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Legal and Policy Approaches
- Regulation 13
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- Device-related Complications 5
- Diagnostic Errors 6
- Discontinuities, Gaps, and Hand-Off Problems 9
- Fatigue and Sleep Deprivation 3
- Identification Errors 1
- Medical Complications 39
- Medication Errors/Preventable Adverse Drug Events 13
- Overtreatment 1
- Psychological and Social Complications 3
- Surgical Complications 17
- Transfusion Complications 2
- Internal Medicine 49
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- Health Care Executives and Administrators 96
Health Care Providers
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Non-Health Care Professionals
- Media 1
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- Australia and New Zealand 1
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Search results for ""
Legislation/Regulation > Federal Legislation
HR 2234, 109th Cong, 1st Sess (2005).
This bill, which garnered bipartisan support, proposes developing health information technology networks (known as "Regional Health Information Organizations," or RHIOs) with a strong focus on state- and community-based efforts. It is presently under consideration in the United States House of Representatives.
Grant > Grant Recipient
Rockville, MD: Agency for Healthcare Research and Quality; June 2005.
The Agency for Healthcare Research and Quality (AHRQ) awarded more than $8 million to 15 Partnerships in Implementing Patient Safety (PIPS) projects. These projects will implement patient safety interventions and develop toolkits that will be freely available to other health care providers.
Hallinan JT. Post-Gazette.com. June 21, 2005.
This article summarizes the history of patient safety improvement in anesthesia and its impact on malpractice claims and costs within that specialty.
Journal Article > Study
Hospital implementation of computerized provider order entry systems: results from the 2003 Leapfrog Group quality and safety survey.
Hillman JM, Given RS. J Healthc Inf Manag. Fall 2005;19:55-65.
The Leapfrog Group's widely recognized efforts to promote patient safety include an initiative to mandate implementation of computerized provider order entry (CPOE) systems at hospitals across the country. This survey of more than 840 participating hospitals demonstrated that while only 3.7% use fully implemented systems, 92% shared plans for at least partial implementation of a CPOE system. Discussion includes analysis of the organizational and financial characteristics of participating hospitals, how hospitals with full implementation differ from those with partial efforts, and various predictors of implementation. Few statistically significant organizational factors were correlated to the variability in CPOE implementation, including profitability, bed size, or penetration of health care maintenance organizations (HMOs). The authors suggest that ongoing changes to financial incentives in health care, such as pay-for-performance, will continue to promote adoption of these technologies that support patient safety.
Journal Article > Study
Cutler DM, Feldman NE, Horwitz JR. Health Aff (Millwood). 2005;24:1654-1663.
This study discovered that implementation of computerized physician order entry (CPOE) systems is a greater reflection of hospital ownership and teaching status than hospital profitability. Using Leapfrog survey data derived from their efforts to reward CPOE adoption, investigators present findings from hospitals with varying degrees of operational CPOE systems. While many have argued that limitation in resources prevents wider implementation, these findings counter those explanations. Interestingly, government hospitals represented the most likely adopters and for-profit organizations the least likely, adding to the notion that these systems are not intended to provide significant profits. Findings suggest that other factors, such as caring for the sickest patients or political interests in safety, may partly explain the results. The authors express concern that less than 5% of hospitals are in compliance with CPOE standards and that changes in the reimbursement environment through federal initiatives may provide necessary stimulus.
Edmonton, AB: Canadian Patient Safety Institute; December 2, 2005.
This news release announces the selection of 28 research and demonstration projects eligible for funding from the Canadian Patient Safety Institute research initiative.
Award > Award Recipient
Indianapolis, IN: Anesthesia Patient Safety Foundation.
This grant program supports research that seeks to improve anesthesia safety and the development of researchers in the specialty. The application process for submitting a grant application for the 2019 funding cycle of the primary solicitation for investigator initiated research (IIR) grants is now closed. Other opportunities for funding become available on a periodic basis.
Baltimore, MD: Centers for Medicare & Medicaid Services (CMS) Office of Public Affairs; May 18, 2006.
This fact sheet provides information regarding the Centers for Medicare and Medicaid Services' initiative to better understand and minimize never events.
The Commonwealth Fund Commission on a High Performance Health System. New York, NY: The Commonwealth Fund; August 2006.
This report calls for providing "safe, well-coordinated, accessible, and efficient" care through five key steps: expanding health insurance coverage, implementing evidence-based patient safety and quality interventions, increasing use of health information technology, public reporting of safety and quality measures, and rewarding achievement in quality through "pay-for-performance." The authors ascribe the current quality problems in the U.S. health care system to system failures, including misaligned payment incentives, inadequate motivation to challenge the status quo, inadequate information systems, duplicative regulatory systems, and an overemphasis on autonomy.
Journal Article > Study
Clement JP, Lindrooth RC, Chukmaitov AS, Chen HF. Med Care. 2007;45:131-138.
This study explores the link between financial reimbursement and patient safety by examining the effect of changes in reimbursement policies and performance on the Agency for Healthcare Research and Quality's Patient Safety Indicators (PSIs). The investigators attempted to control for other factors affecting PSI rates, including nurse-staffing ratios and patient characteristics. Results varied across different payers; decreased Medicare and private insurance reimbursements were associated with worsened patient safety, but changes in Medicaid reimbursement did not have the same effect. While this analysis is preliminary, it may have implications for the burgeoning pay-for-performance movement.
Journal Article > Review
Hwang RW, Herndon JH. Clin Orthop Relat Res. 2007;457:21-34.
The authors discuss the financial incentives of improving patient outcomes as the business case for patient safety.
"The Early Show." CBS News Video. February 7, 2007.
This news video discusses the impact of apology on potential malpractice lawsuits and features a patient and her anesthesiologist discussing how apology helped them to overcome the psychological distress of medical error.
Journal Article > Commentary
Excusable neglect in malpractice suits against radiologists: a proposed jury instruction to recognize the human condition.
Caldwell C, Seamone ER. Ann Health Law. Winter 2007;16:43-77.
The authors discuss the uniqueness of errors in radiology and propose a jury instruction that takes into account errors of perception and judgment.
Talaga T, Cribb R. Toronto Star. March 19, 2007.
This article discusses disclosure of medical errors and shares stories from several Canadian hospitals on their policies for disclosing adverse events.
Kowalczyk L. Boston Globe. March 29, 2007:4B.
This article reports on an award recognizing Beth Israel Deaconess Hospital for its approach to improving patient safety in response to the death of an infant in 2000.
Rowland C. Boston Globe. May 5, 2007:1A.
This article reports on Massachusetts hospitals that are basing hospital executive bonuses on the extent to which their hospitals implement and comply with safety measures.
Abelson R. New York Times. May 17, 2007;Business section:1.
This article reports on a Pennsylvania hospital system that offers a flat fee for bypass surgery and a guarantee for follow-up care should complications arise.
Journal Article > Study
Becker DJ. Health Serv Res. 2007;42:1589-1612.
Prior research has demonstrated that patients admitted to the hospital on a weekend have a higher risk of mortality from conditions requiring emergency treatment and may experience a higher rate of preventable complications. These problems have been attributed to lower hospital staffing ratios on weekends. This article specifically evaluated the quality of care provided to patients hospitalized with acute myocardial infarction (AMI) and found that patients admitted on weekends were significantly less likely to undergo invasive treatments (such as cardiac catheterization or bypass surgery) within the first day of admission. This finding corroborates another recent study, which also found a lower rate of invasive procedure use among AMI patients admitted on the weekend, and also demonstrated increased mortality among those patients. Taken together, these results suggest that both increased staffing and incentives to perform weekend procedures may be needed to counteract the "weekend effect."
Smerd J. Workforce Management. June 11, 2007;1, 16-19.
This article discusses the financial impact on employers when an employee is affected by medical error.
Grant > Grant Announcement
Dublin, OH: Cardinal Health Foundation.
This program funds opportunities for US hospitals, health systems, and community health clinics seeking to develop programs that enhance patient safety. The process for submitting a 2017 proposal is now closed.