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- Study 6
- Slideset 1
- Book/Report 15
- Legislation/Regulation 2
- Newspaper/Magazine Article 22
- Newsletter/Journal 1
- Special or Theme Issue 3
- Toolkit 4
- Web Resource 22
- Press Release/Announcement 1
- Communication between Providers 16
- Culture of Safety 3
- Education and Training 10
- Error Reporting and Analysis 24
- Human Factors Engineering 7
- Legal and Policy Approaches 7
- Logistical Approaches 3
- Quality Improvement Strategies 18
- Specialization of Care 5
- Teamwork 4
- Technologic Approaches 6
- Transparency and Accountability 1
- Device-related Complications 3
- Diagnostic Errors 3
- Discontinuities, Gaps, and Hand-Off Problems 11
- Fatigue and Sleep Deprivation 1
- Identification Errors 7
- Interruptions and distractions 1
- Medical Complications 9
- Medication Errors/Preventable Adverse Drug Events 12
- MRI safety 1
- Nonsurgical Procedural Complications 3
- Psychological and Social Complications 3
- Surgical Complications 13
- Internal Medicine 28
- Surgery 12
- Nursing 1
- Pharmacy 7
- Family Members and Caregivers 2
- Health Care Executives and Administrators 52
Health Care Providers
- Nurses 4
Non-Health Care Professionals
- Media 2
- Patients 9
Search results for ""
Web Resource > Database/Directory
Tucson, AZ: University of Arizona Center for Education and Research on Therapeutics, Arizona Health Sciences Center; 2010.
This tool identifies drugs that affect the cardiac conduction system in a deleterious fashion.
Special or Theme Issue
Expert panel on weight loss surgery. Betsy Lehman Center for Patient Safety and Medical Error Reduction. Evidence-based recommendations for best practices in weight loss surgery.
Obes Res. 2005;13: 203-305.
A report from an expert panel convened to study surgical weight loss programs and procedures from a patient safety perspective. Relevant literature was collected and reviewed to provide evidence-based recommendations.
Patient Safety Initiative Alert. Trenton: New Jersey Department of Health and Senior Services; May 2006.
This announcement describes a near miss involving sandbags filled with metal shot instead of sand.
PA-PSRS Patient Saf Advis. June 2006;3:1-5.
This article shares several examples of errors made while verbally communicating medication orders and includes recommendations for safe practices. A set of tools for educating hospital personnel about this issue is available via the link below.
Harrisburg, PA: Pennsylvania Health Care Cost Containment Council; November 2006.
This report includes findings on the number and rate of infections in Pennsylvania hospitals in 2005.
St. Paul, MN: Minnesota Department of Health; January 2009.
This report provides background on the Minnesota Never Events reporting initiative, tips for patients on how to receive the safest care possible, and a table of events reported by all hospitals in the state.
PA-PSRS Patient Saf Advis. June 2007;4:29, 32-45.
This article discusses reports of wrong-site surgery submitted to the PA-PSRS, compares them with results of other studies, and provides suggestions to reduce this type of error.
Legislation/Regulation > Pennsylvania Legislation
General Assembly of Pennsylvania. SB968 (2007).
This bill requires that Pennsylvania hospitals and nursing homes implement an internal infection control plan and report hospital-acquired infections.
Graham J. Chicago Tribune. August 21, 2007;Metro section:1.
This article discusses a new Illinois state law that requires hospitals to screen all intensive care patients for methicillin-resistant Staphylococcus aureus (MRSA) infections and to isolate infected patients.
Tools/Toolkit > Toolkit
Burlington, MA: Massachusetts Coalition for the Prevention of Medical Errors; 2003.
PA-PSRS Patient Saf Advis. December 2007;4:109, 112-123.
This article summarizes a state-level analysis that used site visits along with near miss and error reports to evaluate wrong-site surgeries.
Saving Lives, Saving Money: The Imperative for Computerized Physician Order Entry in Massachusetts Hospitals.
Adams M, Bates D, Coffman G, Everett W. Westborough, MA: Massachusetts Technology Collaborative and New England Healthcare Institute; 2008.
Analyzing patient charts at six community hospitals in Massachusetts, this report reveals to what extent adopting computerized physician order entry could affect clinical outcomes and impart financial savings.
PA-PSRS Patient Saf Advis. September 2008;5:75-80.
This article analyzed reports of medication errors due to patient allergies and found that lack of patient or drug information contributed to many of these errors.
Tools/Toolkit > Multi-use Website
Washington State Hospital Association.
This Web site provides toolkits and information to help Washington hospitals adopt standard practices for emergency code calls, surgery preparation, isolation precautions, and wristband use.
The High Costs of Weak Compliance With the New York State Hospital Adverse Event Reporting and Tracking System.
Thompson WC Jr. New York, NY: Office of the New York City Comptroller, Office of Policy Management; 2009.
This report assesses the New York State Department of Health's New York Patient Occurrence and Tracking System (NYPORTS). It observes trends of adverse event reporting, finds that New York City hospitals report dramatically fewer events per discharge, explores reasons for underreporting, and discusses the impact on safety improvement efforts.
PA-PSRS Patient Saf Advis. March 2009;6:16-19.
This article discusses strategies to ensure safe transitions for patients between hospital departments. These strategies include transport team development, use of standardized communication tools, and educational programming for unlicensed health care personnel.
Fillo KT. Bureau of Health Care Safety and Quality, Department of Public Health. Boston, MA: Commonwealth of Massachusetts; July 2018.
This report compiles patient safety data documented by Massachusetts hospitals. The latest numbers represent a modest decrease in serious reportable events recorded in acute care hospitals, from 1012 the previous year to 922. This presentation also includes events from ambulatory surgery centers. Previous years reports are also available.
PA-PSRS Patient Saf Advis. June 2009;6:39-45.
This piece identifies risk factors associated with retention of foreign objects and suggests several tactics to prevent its occurrence.
Journal Article > Study
Blanco M, Clarke JR, Martindell D. AORN J. 2009;90:215-222.
Journal Article > Study
A comprehensive perinatal patient safety program to reduce preventable adverse outcomes and costs of liability claims.
Simpson KR, Kortz CC, Knox E. Jt Comm J Qual Patient Saf. 2009;35:565-574.
An organization-wide quality improvement program resulted in reductions in perinatal adverse events over a 5-year period.