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- Communication Improvement 2
- Culture of Safety 6
- Error Reporting and Analysis
- Human Factors Engineering 1
- Legal and Policy Approaches 5
- Quality Improvement Strategies 6
- Specialization of Care 1
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Perspectives on Safety > Perspective
Organizational Change in the Face of Highly Public Errors—I. The Dana-Farber Cancer Institute Experience
with commentary by James B. Conway; Saul N. Weingart, MD, PhD, Errors in the Media and Organizational Change, May 2005
A decade ago, two tragic medical errors rocked one of the world’s great cancer hospitals, Dana-Farber Cancer Institute (DFCI) in Boston, to its core. The errors led to considerable soul searching and, ultimately, a major change in institutional practices a...
Hospital-error oversight called lax: state takes too long to investigate mistakes, patient advocates say.
Galloway A. Seattle Post-Intelligencer. May 5, 2005.
This article explores inefficiencies in the process for reporting and investigating adverse events in Washington and indicates that inconsistent error review is a problem across the nation.
Legislation/Regulation > Federal Legislation
S 1337, 109th Cong, 1st Sess (Mt 2005).
This bill was introduced in the U.S. Senate to encourage alternatives to the current medical malpractice system (by creating a "health care court") and to promote early disclosure and resolution of medical errors.
Wolosin R, Vercler L, Matthews J. Patient Safety & Quality Healthcare. November/December 2005;2:40-44.
The authors examined patients' perceptions of safety in hospital settings and factors that affect their perceptions.
Journal Article > Commentary
Clinton HR, Obama B. N Engl J Med. 2006;354:2205-2208.
This commentary is written by Senators Hillary Rodham Clinton (D-NY) and Barack Obama (D-IL), who coauthored the National Medical Error Disclosure and Compensation (MEDiC) Act. Providing context for the bill, the senators advocate for necessary improvements in patient safety and the medical liability environment through a series of important and interdependent strategies. These include reducing the rates of preventable patient injuries, promoting open communication between physicians and patients, ensuring patients' access to fair compensation for legitimate medical injuries, and reducing liability insurance premiums for providers. The senators further discuss the implications of each approach and specifically outline the major provisions of the bill, including how it will foster and promote the necessary improvement efforts.
Journal Article > Study
Stebbing C, Kaushal R, Bates DW. Pediatrics. 2006;117:1907-1914.
This study analyzed newspaper coverage of pediatric medication errors and adverse drug events in five countries to demonstrate increased interest in the topic over the past decade. Investigators examined the number of articles and the types of events covered and assessed the overall themes presented and framed by the media. The majority of articles published covered patient incidents followed by policy and then research in decreasing order of frequency. Despite the occasional occurrence of sensational reporting on errors, more than 70% of articles that were deemed to be negatively associated with patient safety were covered in a neutral manner.
Scobie S, Minghella E, Dale C, Thomson R, Lelliott P, Hill K. London, UK: National Patient Safety Agency; July 2006.
This report, the second in a series from the United Kingdom's National Patient Safety Agency, analyzes nearly 45,000 patient safety incidents relating to mental health that were reported to a nationwide incident reporting system. The majority of reported incidents were from inpatient mental health facilities, primarily involving patient accidents (including falls), disruptive or aggressive behavior, self-harming behavior, and missing (absconding) patients. The report summarizes existing initiatives to improve patient safety in mental health, makes specific recommendations for mental health providers, and identifies priority areas for future research.
Journal Article > Commentary
SQUIRE 2.0 (Standards for QUality Improvement Reporting Excellence): revised publication guidelines from a detailed consensus process.
Ogrinc G, Davies L, Goodman D, Batalden P, Davidoff F, Stevens D. BMJ Qual Saf. 2016;25:986-992.
The rapid growth in literature on patient safety and quality improvement (QI) has been accompanied by controversy about how such studies should be conducted and reported. Influential leaders have argued that QI studies demand a different standard of evaluation than traditional biomedical research, given their complexity. A contrary argument notes that failure to rigorously evaluate such research could result in wasted resources and unanticipated consequences if poorly evaluated interventions are widely implemented. Developed by expert consensus, these guidelines provide a blueprint for reporting the results of QI studies. Since its introduction in 2008, authors and journal editors have widely adopted these guidelines to standardize reporting of safety and QI studies. In 2015, the SQUIRE guidelines were revised through a process that included semistructured interviews, focus groups, consensus meetings, pilot testing with authors, and a public comment period. SQUIRE 2.0 improves the usability of the guidelines and omits the multiple sub-items that were felt to be too confusing for authors in the initial document.
Healthcare Commission. London, England: Commission for Healthcare Audit and Inspection; 2008. ISBN: 9780102958362.
This report assesses care in the United Kingdom, provides data on a variety of issues related to safety, and makes recommendations to support improvements over time.
Rockville, MD: Agency for Healthcare Research and Quality.
In this annual publication, AHRQ reviews the results of the National Healthcare Quality Report and National Healthcare Disparities Report. Providing a 5-year update on the National Quality Strategy, this report highlights that a wide range of quality measures have shown improvement in quality, access, and cost.
Rau J. Kaiser Health News. October 17, 2011.
The Centers for Medicare & Medicaid Services (CMS) published data on hospital-acquired conditions in a 2011 report. This news article discusses new data available on the Hospital Compare Web site, including preventable complications and certain types of medical errors.
Web Resource > Government Resource
Division of Licensing and Regulatory Services, Maine Department of Health and Human Services.
This Web site provides information about Maine's statewide incident reporting initiative and includes annual sentinel event reports.
Utrecht, Netherlands: European Network for Patient Safety; 2010.
This report identifies care process and outcome indicators in the European Union and describes how the indicators relate to patient safety culture.
This Web site summarizes patient safety improvement efforts in Tennessee and provides access to an annual report of their efforts and a calendar of training opportunities.
Washington, DC: Department of Veterans Affairs, Office of Inspector General. March 7, 2018. Report No. 17-02644-130.
Systemic weaknesses in the Veterans Affairs health system have resulted in high-profile failures. Highlighting concerns at one medical center that were found to contribute to opportunities for waste, fraud, and poor health care delivery, this report by the Office of Inspector General outlines 40 recommendations to address deficiencies.