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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...
Perspectives on Safety > Interview
International Perspectives on Safety, May 2007
Sir Liam Donaldson, MD, MSc, is England's Chief Medical Officer, a post often referred to as "the Nation's Doctor" (similar to the role of the U.S. Surgeon General). Trained as a surgeon, Sir Liam has been an inspirational leader in public health and health care quality in the United Kingdom for two decades. He has also emerged as a world leader in the patient safety field, authoring or commissioning dozens of influential reports, and serving as the founding chair of the World Health Organization's World Alliance for Patient Safety. We spoke to him about patient safety from an international perspective.
Perspectives on Safety > Interview
The Patient's Role in Safety, March 2007
Sorrel King is the mother of Josie King, who died tragically in 2001 at age 18 months because of medical errors during a hospitalization at Johns Hopkins Hospital. She has subsequently become one of the nation’s foremost patient advocates for safety, forming an influential foundation (the Josie King Foundation) and partnering with Johns Hopkins to promote the field of patient safety around the world.
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 > 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.
Journal Article > Study
Soleimani F. N Z Med J. 2006;119:U2099.
The author surveyed New Zealand physicians regarding their medical error reporting behaviors. Most respondents felt they should report an error to both the patient and hospital if a major adverse event was anticipated, but they were less likely to report errors with minor complications.
Journal Article > Study
Hinchcliff R, Westbrook J, Greenfield D, Baysari M, Moldovan M, Braithwaite J. Int J Qual Health Care. 2012;24:1-8.
Poll: Many Sick Americans Experience Significant Financial Problems and Report Their Care is not Well-Managed.
Princeton, NJ: Robert Wood Johnson Foundation, National Public Radio, and the Harvard School of Public Health. May 21, 2012.
This report describes findings from a poll that investigated how cost of care and health insurance affect patients' experiences of health care quality and safety in the United States.
Howard B. AARP The Magazine. April/May 2013;56:46-50,52,71.
This magazine article details how several hospitals have taken a comprehensive approach to improving patient safety in their organizations. An interactive graphic displays many of the methods being used; an accompanying tool lists hospitals and their safety features.
Jain M. Washington Post. May 27, 2013.
Harrow, Middlesex, UK: The Patients Association; 2013.
This publication provides patient and family accounts of incidents involving inadequate care or harm and highlights the need for improvements recommended in a National Health Services report.
Bernhard B, Kohler J. St. Louis Post-Dispatch. August 1, 2010:A1
In the context of system failures that contributed to the death of a patient, this newspaper article describes how never events are rarely publicized, even though hospital inspection reports are public records.
Journal Article > Commentary
Dudzinski DM, Hébert PC, Foglia MB, Gallagher TH. N Engl J Med. 2010;363:978-986.
Error disclosure policies for events that affect individual patients have traditionally focused on what information to share and how to share it; of course, discussions about individual disclosure occur in the context of the active debate about whether disclosure has an impact on liability risk. This study discusses large-scale adverse events (such as failure to sterilize an endoscope used on scores of patients), which harm or carry a potential to harm groups of patients, and how individual organizations should manage their disclosure process. Drawing on a number of representative cases, the authors recommend key elements for a disclosure policy. They include developing an institutional policy, planning proactively for disclosures, communicating with the public, and planning for appropriate patient follow-up. Although the authors point out the challenge these events often raise, they advocate for disclosure as a norm to reinforce transparency, trust, and integrity with the public.
Rosenberg T. New York Times. December 4, 2013.
Preventable adverse events may result in more harm than previously thought. Highlighting inconsistencies in publicly reported hospital safety data, this newspaper article explains how information is collected, analyzed, and presented by organizations such as Hospital Compare, Consumer Reports, and Leapfrog.
Khullar D. New York Times. May 15, 2014.
Cohn M. Baltimore Sun. July 26, 2014.
This news article reports weaknesses in a Maryland reporting program, including poor understanding about which errors should be reported and lack of regulations regarding disclosure. Limited public access to comprehensive incident reports and insufficient performance measurement hinder consumers' ability to select hospitals based on safety.
O'Donnell J. USA Today. August 6, 2014.
This newspaper article reports on changes to publicly reported data on the Hospital Compare Web site. Several avoidable hospital-acquired conditions, such as air embolism or retained foreign objects, are no longer included. Working with the National Quality Forum, the Centers for Medicare and Medicaid Services (CMS) decided to modify the list to make it easier for consumers to use and understand.
Kowalczyk L. Boston Globe. August 31, 2014.
Reporting on an incident involving administration of an inappropriate dye which led to a patient's death, this newspaper article reveals how cognitive biases may have played a role and steps the hospital took to prevent similar errors. Six Massachusetts hospitals have launched a pilot program for early apology and resolution in an effort to enhance patient satisfaction and safety.
Gubar S. New York Times. October 30, 2014.
This newspaper article describes how surgical complications, health care–associated infections, and ineffective patient–provider communication contributed to a patient's experience with harm and suggests that transparency around the incident and preoperative patient briefings could have improved the situation.
Koba M. Fortune. January 6, 2015.