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National Quality Forum. Washington, DC: National Quality Forum; 2010.
The National Quality Forum originally published the Safe Practices for Better Healthcare in 2003. These practices are intended to be universally applicable, "gold standard" interventions for reducing preventable harm, and have been widely endorsed and implemented. As in the 2009 update, the 34 specific practices are organized into seven content areas: creating a culture of safety, providing patient-centered care and disclosing errors, matching health care needs with delivery capacity, facilitating information transfer and clear communication between providers, managing medications safely, preventing health care–associated infections, and implementing safe practices for specific clinical conditions and sites of care. There are no major changes in the recommended practices since 2009, but the report contains specific recommendations on engaging patients and families in safety efforts.
Austin, TX: Texas Medical Institute for Technology and the Quaid Foundation; 2010.
This documentary reports on families affected by medical errors; it includes the story of a high-profile heparin overdose and how it transformed the family of actor Dennis Quaid into advocates for patient safety.
Journal Article > Study
Bishop TF, Ryan AK, Casalino LP. JAMA. 2011;305:2427-2431.
Analyzing malpractice claims is a common strategy for evaluating potential patient safety issues, particularly in high-risk settings such as surgery, anesthesia, and obstetrics and gynecology. This study conducted a similar analysis of paid malpractice claims and found that 43% occurred in the ambulatory setting, a notable increase from 2005 to 2009. The most common reason for a paid claim was diagnostic in the ambulatory setting (similar to findings from a past study) and surgical in the inpatient setting. Major injury and death were the two most common outcomes in both settings with mean payment amount significantly higher in the inpatient setting. Advocating for effective risk management programs, an accompanying editorial [see link below] highlights how malpractice risk is increasing and under-recognized in the ambulatory setting. A past AHRQ WebM&M conversation and perspective discuss the intersection between risk management and patient safety.