Narrow Results Clear All
- Review 2
- Study 8
- Slideset 1
- Book/Report 28
- Legislation/Regulation 1
- Newspaper/Magazine Article 78
- Toolkit 3
- Web Resource 20
- Communication Improvement 32
- Culture of Safety 9
- Education and Training 22
Error Reporting and Analysis
- Error Reporting 38
- Human Factors Engineering 14
- Legal and Policy Approaches 52
- Logistical Approaches 10
Quality Improvement Strategies
- Benchmarking 11
- Specialization of Care 6
- Teamwork 3
- Clinical Information Systems 5
- Transparency and Accountability 5
- Device-related Complications 7
- Diagnostic Errors 6
- Discontinuities, Gaps, and Hand-Off Problems 12
- Drug shortages 1
- Fatigue and Sleep Deprivation 3
- Identification Errors 5
- Interruptions and distractions 1
- Medical Complications 39
- Medication Safety 18
- Nonsurgical Procedural Complications 2
- Psychological and Social Complications 10
- Surgical Complications 20
- Transfusion Complications 3
- Surgery 5
- Nursing 4
- Pharmacy 4
- Family Members and Caregivers 14
- Health Care Executives and Administrators 40
Health Care Providers
- Nurses 3
- Physicians 11
Non-Health Care Professionals
- Media 4
- Australia and New Zealand 1
- Europe 14
- Canada 4
Search results for ""
Washington, DC: Leapfrog Group.
This website offers resources related to the Leapfrog Hospital Survey investigating hospitals' progress in implementing specific patient safety practices. Updates to the survey include increased time allotted to complete computerized provider order entry evaluation, staffing of critical care physicians on intensive care units, and use of tools to measure safety culture. Reports discussing the results are segmented into specific areas of focus such as health care-associated infections and medication errors.
Journal Article > Commentary
Medication errors in family practice, in hospitals and after discharge from the hospital: an ethical analysis.
Clark PA. J Law Med Ethics. 2004;32:349-357.
In this article, the author urges the medical community to universally apply the systems approach to safety toward the reduction of medical errors. The author calls for health care to take medication errors more seriously and for patients to help drive improvement.
Dembner A. Boston Globe. July 3, 2006;Health Science section:A1.
This article reports on the movement to improve care in nursing homes in order to decrease unnecessary hospitalizations for elderly patients.
Journal Article > Study
Diagramming patients' views of root causes of adverse drug events in ambulatory care: an online tool for planning education and research.
Brown M, Frost R, Ko Y, Woosley R. Patient Educ Couns. 2006;62:302-315.
Kapadia R. Smart Money. October 2006;15:112-114.
This article provides tips for consumers to help keep their hospital care as safe and hassle-free as possible.
Berwick DM, Leape LL. Newsweek. October 16, 2006:70-71.
As part of the "Health for Life" series, Drs. Berwick and Leape discuss the notion of completely eliminating medical errors and share stories about several hospitals' efforts to raise safety standards.
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.
Zimmerman R. Wall Street Journal. February 6, 2007:A1.
This article reports on a mother's campaign to educate parents about kernicterus and to make bilirubin tests standard for all newborns.
Victoria Times Colonist. March 26, 2007.
This article reports on findings from an investigation into hospital-acquired infections in British Columbia.
Golden, CO: HealthGrades, Inc.; April 2007.
This fourth annual report on the safety of hospitalized Medicare patients builds on past efforts to evaluate hospital performance. The report uses the Agency for Healthcare Research and Quality's Patient Safety Indicators to provide benchmarks for such performance, identify current trends in safety issues, and estimate preventable events nationally. The report suggests that the patient safety incidents captured account for nearly $9 billion in excess cost during 2003-2005, and nearly 250,000 potentially preventable deaths occurred during the same time period. Grading for all states and a selected group of highly rated hospitals is included with the implication that, if all hospitals performed at a level comparable to the ones acknowledged, more than 34,000 Medicare deaths could be avoided with a cost savings of $1.74 million. As with the second and third annual reports, several methodological limitations exist, and the reports themselves did not receive external peer review.
Landro L. Wall Street Journal. July 11, 2007:D1.
This article reports on hospitals that are creating dedicated teams of experts who have the skills to perform risky medical procedures.
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.
Landro L. Wall Street Journal. August 8, 2007:D1.
This article discusses the development of programs to actively involve patients in administrative, policy, and safety work in hospitals.
Pear R. New York Times. August 19, 2007.
This article reports on a new Centers for Medicare and Medicaid Services (CMS) rule mandating that Medicare will no longer pay for treating certain preventable errors starting in 2008, including some hospital-acquired infections, decubitus ulcers, and retained foreign bodies. The policy is generating considerable discussion in patient safety circles, with some expressing concerns regarding the economic impact on hospitals and the increased efforts it is likely to create for hospitals to document certain patient problems present at the time of admission.
Ottawa, ON, Canada: Canadian Institute for Health Information; August 14, 2007.
Using survey data as well as information on patient safety indicators, this report provides an update on the frequency of certain types of errors and incidents in Canada.
Kershaw S. New York Times. Sepember 7, 2007;Metro Desk section:B1.
This article reports on an initiative to publish data on mortality and hospital-acquired infections in New York City public hospitals.
Lerner M. Star Tribune. September 18, 2007;News section:5B.
This article reports on Minnesota's adoption of a policy for hospitals to not charge patients or insurers for never events or consequent treatment.
Kowalczyk L. Boston Globe. September 17, 2007;Metro section:1A.
This article reports on how numerous Massachusetts hospitals have implemented policies to waive charges for the set of serious errors categorized as never events.
Gross T. "Fresh Air." National Public Radio. January 9, 2008.
This interview with Richard Shannon, MD, addresses the safety consequences of hospital-acquired infections and discusses prevention tactics for health care leaders and front-line providers.