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- Review 1
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- Newspaper/Magazine Article 31
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- Special or Theme Issue 3
- Glossary 2
- Toolkit 44
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- Bibliography 1
- Clinical Guideline 1
- Grant 20
- Meeting/Conference 16
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Education and Training
- Students 1
Error Reporting and Analysis
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Human Factors Engineering
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Legal and Policy Approaches
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Quality Improvement Strategies
- Benchmarking 22
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- Device-related Complications 44
- Diagnostic Errors 15
- Discontinuities, Gaps, and Hand-Off Problems 37
- Drug shortages 7
- Failure to rescue 1
- Fatigue and Sleep Deprivation 4
- Identification Errors 13
- Interruptions and distractions 1
- Medical Complications 82
- Medication Errors/Preventable Adverse Drug Events 94
- MRI safety 3
- Nonsurgical Procedural Complications 10
- Psychological and Social Complications 13
- Surgical Complications 38
- Transfusion Complications 1
- Ambulatory Care 86
- General Hospitals 44
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- Health Care Executives and Administrators 417
Health Care Providers
- Nurses 18
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Non-Health Care Professionals
- Educators 21
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United States of America
United States Federal Government
- Department of Health and Human Services (HHS) 405
- United States Federal Government 466
Search results for "Government Resource"
- Government Resource
Grant > Government Resource
Rockville, MD: Agency for Healthcare Research and Quality; June 2008.
This announcement describes the 19 projects funded by the Agency for Healthcare Research and Quality in 2006 that studies the potential of simulation to improve patient safety.
Meeting/Conference > Government Resource
US Food and Drug Administration Center for Drug Evaluation and Research, Institute for Safe Medication Practices. November 7, 2006.
This teleconference discussed the 2006 FDA medication package insert design program and reviewed prescription drug labeling format changes. Handouts and an audio download of the presentation are available.
East Perth, WA, Australia: Department of Health of Western Australia; 2006.
This report shares the 2005-2006 results of Western Australia's sentinel event reporting program and documents a reduction in two types of events: wrong site/wrong part surgeries and retained foreign objects.
Journal Article > Government Resource
Centers for Disease Control and Prevention. MMWR Morb Mortal Wkly Rep. 2006;55:1016-1017.
This article reports on an investigation into clusters of mistakes involving the misadministration of a vaccine.
The Health Literacy of America's Adults: Results from the 2003 National Assessment of Adult Literacy.
Kutner M, Greenberg E, Jin Y, Paulsen C. US Department of Education. Washington, DC: National Center for Education Statistics; September 2006. Report No: NCES 2006-483.
This report provides an assessment of health literacy data analyzed for different demographic characteristics.
Rockville, MD: Center for Devices and Radiological Health, US Food and Drug Administration; August 29, 2006.
This news release announces a seizure of infusion pumps that have a "key bounce" defect that could result in over-infusion of medication.
Office of the Inspector General. Washington, DC: US Department of Health and Human Services; August 2006. Report No. OEI-06-05-00060.
This report shares findings from an inspection of the FDA's National Drug Code Directory, which found that the directory is both incomplete and inaccurate in its listings of marketed prescription medications.
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.
Roxane Laboratories Initiates a Nationwide Voluntary Recall of a Single Manufacturing Lot of Azathioprine Tablets in the U.S. and Puerto Rico.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; July 13, 2006.
This news release announces the recall of a manufacturing lot of Azathioprine. Bottles may have been erroneously filled with another medication, which could lead to serious health effects for those taking the drug.
Office of the Inspector General. Washington, DC: US Department of Health and Human Services; July 2006. Report No. OEI-01-04-00340.
This report shares findings from an assessment of Centers for Medicaid and Medicare Services response to nursing home complaints. The report identifies weaknesses in the current investigation process and provides recommendations for improvement.
Washington, DC: United States Government Accountability Office; June 2006. Publication GAO-06-416.
This government report found that the clinical laboratory survey process is flawed, allowing safety requirements to be bypassed.
Tools/Toolkit > Government Resource
Huntington Valley, PA: Institute for Safe Medication Practices.
This Web site includes tools to help raise awareness about potential medication errors associated with using certain abbreviations. The tools are made available by Institute for Safe Medication Practices (ISMP) and U.S. Food and Drug Administration (FDA) as part of their national educational effort to eliminate the use of these abbreviations.
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.
Web Resource > Government Resource
National Blood Service Hospitals.
This Web site includes reports from audits on compliance with blood transfusion guidelines in the United Kingdom.
VA Health Care: Steps Taken to Improve Practitioner Screening, but Facility Compliance with Screening Requirements is Poor.
Washington, DC: United States Government Accountability Office; May 2006. Publication GAO-06-544.
This investigation determined that the U.S. Veterans Administration has taken steps to improve the reliability of their practitioner licensure and certification screening processes for employees and new hires but found that some weaknesses still exist.
VA Health Care: Selected Credentialing Requirements at Seven Medical Facilities Met, but an Aspect of Privileging Process Needs Improvement.
Washington, DC: United States Government Accountability Office; May 2006. Publication GAO-06-648.
This report reviews findings from a federal inspection indicating that Veterans Affairs (VA) facilities, while complying with basic credentialing policies, are not routinely submitting malpractice data as required to be used by the VA to inform privileging determinations.
Web Resource > Government Resource
New Jersey Department of Health and Senior Services.
This Web site supports the data collection and educational initiatives associated with New Jersey's incident reporting program. The site includes reporting forms, instructions, and a patient safety newsletter.
FDA Alert [US Food and Drug Administration Web site]. April 25, 2006.
This alert highlights the dangers of administering promethazine hydrochloride to young children and includes information sheets for both patients and health care professionals.
Health Care Inspection. Washington, DC: VA Office of Inspector General; April 10, 2006. Report No. 06-01642-126.
This report shares the results of an inspection into two mistakes at a Veterans Affairs (VA) health facility involving appropriate sterilization of implantable medical devices.
VA National Center for Patient Safety. Washington, DC: VA Central Office; April 6, 2006. Patient Safety Alert AL06-012.
This alert reports five instances of accidental infusion into an IV or peripherally inserted central catheter (PICC) line and suggests actions for preventing similar errors.