Narrow Results Clear All
- Study 2
- Slideset 1
- Book/Report 10
- Legislation/Regulation 1
- Newspaper/Magazine Article 7
- Special or Theme Issue 1
- Toolkit 1
- Web Resource 14
- Communication Improvement 8
- Culture of Safety 1
- Education and Training 4
- Error Reporting and Analysis 14
- Human Factors Engineering 2
- Legal and Policy Approaches 3
- Logistical Approaches 2
- Quality Improvement Strategies 8
- Specialization of Care 2
- Teamwork 1
- Technologic Approaches 3
- Device-related Complications 2
- Diagnostic Errors 1
- Discontinuities, Gaps, and Hand-Off Problems 6
- Fatigue and Sleep Deprivation 1
- Identification Errors 2
- Medical Complications 7
- Medication Errors/Preventable Adverse Drug Events 4
- Psychological and Social Complications 2
- Surgical Complications 7
- Health Care Executives and Administrators 25
Health Care Providers
- Nurses 2
Non-Health Care Professionals
- Media 1
- Patients 5
Search results for ""
Web Resource > Database/Directory
Tucson, AZ: University of Arizona Center for Education and Research on Therapeutics, Arizona Health Sciences Center; 2010.
This tool identifies drugs that affect the cardiac conduction system in a deleterious fashion.
Harrisburg, PA: Pennsylvania Health Care Cost Containment Council; November 2006.
This report includes findings on the number and rate of infections in Pennsylvania hospitals in 2005.
Legislation/Regulation > Pennsylvania Legislation
General Assembly of Pennsylvania. SB968 (2007).
This bill requires that Pennsylvania hospitals and nursing homes implement an internal infection control plan and report hospital-acquired infections.
Graham J. Chicago Tribune. August 21, 2007;Metro section:1.
This article discusses a new Illinois state law that requires hospitals to screen all intensive care patients for methicillin-resistant Staphylococcus aureus (MRSA) infections and to isolate infected patients.
Saving Lives, Saving Money: The Imperative for Computerized Physician Order Entry in Massachusetts Hospitals.
Adams M, Bates D, Coffman G, Everett W. Westborough, MA: Massachusetts Technology Collaborative and New England Healthcare Institute; 2008.
Analyzing patient charts at six community hospitals in Massachusetts, this report reveals to what extent adopting computerized physician order entry could affect clinical outcomes and impart financial savings.
PA-PSRS Patient Saf Advis. September 2008;5:75-80.
This article analyzed reports of medication errors due to patient allergies and found that lack of patient or drug information contributed to many of these errors.
Tools/Toolkit > Multi-use Website
Washington State Hospital Association.
This Web site provides toolkits and information to help Washington hospitals adopt standard practices for emergency code calls, surgery preparation, isolation precautions, and wristband use.
The High Costs of Weak Compliance With the New York State Hospital Adverse Event Reporting and Tracking System.
Thompson WC Jr. New York, NY: Office of the New York City Comptroller, Office of Policy Management; 2009.
This report assesses the New York State Department of Health's New York Patient Occurrence and Tracking System (NYPORTS). It observes trends of adverse event reporting, finds that New York City hospitals report dramatically fewer events per discharge, explores reasons for underreporting, and discusses the impact on safety improvement efforts.
PA-PSRS Patient Saf Advis. March 2009;6:16-19.
This article discusses strategies to ensure safe transitions for patients between hospital departments. These strategies include transport team development, use of standardized communication tools, and educational programming for unlicensed health care personnel.
Fillo KT. Bureau of Health Care Safety and Quality, Department of Public Health. Boston, MA: Commonwealth of Massachusetts; July 2018.
This report compiles patient safety data documented by Massachusetts hospitals. The latest numbers represent a modest decrease in serious reportable events recorded in acute care hospitals, from 1012 the previous year to 922. This presentation also includes events from ambulatory surgery centers. Previous years reports are also available.
Trenton, NJ: New Jersey Department of Health and Senior Services; March 2012.
PA-PSRS Patient Saf Advis. March 2010;7:9-17.
This article analyzed 2685 event reports involving insulin and found that the most common error types were drug omission, wrong-dose, and wrong-drug errors.
Salt Lake City, UT: Utah Department of Health, Utah Hospitals & Health Systems Association, and HealthInsight; March 10, 2010.
This brief provides information on 101 sentinel events reported to the state of Utah in 2009. The report also includes background on efforts to address such incidents.
Journal Article > Commentary
Lacker C. Am J Nurs. 2011;111:65-69.
Analyzing data from the Pennsylvania Patient Safety Authority Reporting System, this commentary identifies contributing factors to readmissions and suggests tactics to prevent them.
Journal Article > Study
Anticipated consequences of the 2011 duty hours standards: views of internal medicine and surgery program directors.
Shea JA, Willett LL, Borman KR, et al. Acad Med. 2012;87:895-903.
Conducted before implementation of the 2011 ACGME duty hour limits, this survey found that the majority of internal medicine and surgery program directors believed the new regulations would negatively affect the learning environment and continuity of care, as well as result in increased faculty workload and require changes in clinical services.
Special or Theme Issue
FIRST Do No Harm. December 2012;1-8.
This newsletter issue highlights initiatives and tools developed to improve handoff communication in Massachusetts.
Feil M. PA-PSRS Patient Saf Advis. March 2013;10:1-10.
Analyzing data submitted to the Pennsylvania Patient Safety Reporting System, this piece outlines the types of distractions that contribute to medical errors and recommends strategies to mitigate them.
Rensselaer, NY: Healthcare Association of New York State; October 2013.
This publication assessed 10 widely disseminated hospital report cards by criteria including transparency of methodology, evidence-based measures, and data quality. While inconsistent methods across reports hindered direct comparisons, a few reports received high marks.
PA-PSRS Patient Saf Advis. September 2010;7:76-86.
Analyzing reports of diagnostic errors, this article discusses common causes and provides suggestions for physicians and patients to prevent such events.
Journal Article > Commentary
Huber C, Blanco M. Am J Nurs. 2010;110:66-69.
This article discusses problems associated with discharge and highlights the importance of beginning the planning process at admission and engaging the team to ensure successful discharge.