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- Communication Improvement 3
- Culture of Safety 4
Education and Training
- Students 1
- Error Reporting and Analysis
- Human Factors Engineering 3
- Legal and Policy Approaches 3
- Logistical Approaches 2
- Quality Improvement Strategies 1
- Specialization of Care 2
- Teamwork 4
- Technologic Approaches
- Device-related Complications 2
- Diagnostic Errors 2
- Discontinuities, Gaps, and Hand-Off Problems 1
- Fatigue and Sleep Deprivation 1
- Identification Errors 1
- Medical Complications 4
- Medication Safety 4
- Nonsurgical Procedural Complications 1
- Surgical Complications 1
- Health Care Executives and Administrators 10
- Health Care Providers 8
- Non-Health Care Professionals 9
- Patients 2
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Perspectives on Safety > Perspective
with commentary by Ashish K. Jha, MD, MPH, The Transformation of Patient Safety at the VA, September 2006
Five years after the landmark Crossing the Quality Chasm report by the Institute of Medicine (IOM), the quality and safety of health care in the United States remains far from ideal.(1) It is easy to feel pessimistic. Can health care organizations really...
Perspectives on Safety > Interview
Patient Safety Programs, July 2006
Allan Frankel, MD, is Director of Patient Safety for Partners HealthCare, the merged entity of Harvard hospitals and clinics that includes Massachusetts General and Brigham and Women's Hospital. Dr. Frankel, an anesthesiologist by training, has been a key member of the faculty of the Institute for Healthcare Improvement, co-chairing numerous Adverse Drug Events and Patient Safety Collaboratives. Dr. Frankel's work in patient safety focuses on leadership training, high reliability in health care, teamwork development, and cultural change. We asked Dr. Frankel to speak with us about developing a comprehensive patient safety program.
Journal Article > Commentary
A multifaceted approach to improve patient safety, prevent medical errors and resolve the professional liability crisis.
Weinstein L. Am J Obstet Gynecol. 2006;194:1160-1165; discussion 1165-1167.
The author provides background on the professional liability crisis and suggests that focus should be on changes to risk management, professional liability insurance, and the tort system.
Arnst C. Business Week. July 17, 2006.
This article discusses improvements made at U.S. Veterans Affairs' hospitals as well as unique elements of the system that support safe and high-quality care.
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.
Special or Theme Issue
Pediatr Crit Care Med. 2007;8(suppl):S1-S43.
This supplement covers issues related to safety indicators, fatigue, electronic medical records, infection, and disclosure of medical errors in the care of critically ill children.
Legislation/Regulation > Government Resource
Council recommendation on patient safety, including the prevention and control of healthcare associated infections.
Council of the European Union (2009).
This document provides a series of suggestions to improve patient safety in health care systems across the European Union.
Journal Article > Review
Woodward HI, Mytton OT, Lemer C, et al. Annu Rev Public Health. 2010;31:479-497.
This narrative review provides a broad perspective on the current understanding of medical errors and the evidence behind commonly adopted prevention strategies. The authors then highlight a series of recommendations to improve patient safety.
Journal Article > Study
What can apologies in the electronic health record tell us about health care quality, processes, and safety?
Matulis JC III, North F. J Patient Saf. 2018 Jul 17; [Epub ahead of print].
This observational study of the presence of apology documentation in the electronic health record found that approximately half of the apologies were related to errors. Researchers examined apologies and identified specific issues that were not uncovered using standard error reporting. The authors suggest reviewing apologies in clinical documentation in order to detect errors.
Special or Theme Issue
Health Aff (Millwood). 2018;37:1723-1908.
The Institute of Medicine report, To Err Is Human, marked the founding of the patient safety field. This special issue of Health Affairs, published 20 years after that report, highlights achievements and progress to date. One implementation study of evidence-based surgical safety checklists demonstrated that leadership involvement, intensive activities, and engagement of frontline staff are all critical to successful adoption of safety practices. Another study demonstrated that communication-and-resolution programs either decreased or did not affect malpractice costs, providing further support for implementing such programs. Experts describe the critical role of human factors engineering in patient safety and outline how to enhance the use of these methods. The concluding editorial by David Bates and Hardeep Singh points to progress in reducing hospital-acquired infections and improving medication safety in acute care settings and highlights remaining gaps in the areas of outpatient care, diagnostic errors, and electronic health record safety. In the related information, the Moore Foundation provides free access to five articles in this special issue.
Journal Article > Commentary
Gupta A, Jain S, Croft C. JAMA. 2019;321:504-505.