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- Study 6
- Book/Report 32
- Legislation/Regulation 3
- Newspaper/Magazine Article 8
- Newsletter/Journal 1
- Special or Theme Issue 1
- Toolkit 1
- Web Resource 26
- Award 1
- Press Release/Announcement 4
- Communication Improvement 4
- Culture of Safety 4
- Education and Training 3
- Error Reporting and Analysis
- Human Factors Engineering 7
Legal and Policy Approaches
- Regulation 13
- Quality Improvement Strategies 14
- Teamwork 1
- Technologic Approaches 7
- Transparency and Accountability 3
- Device-related Complications 11
- Diagnostic Errors 1
- Discontinuities, Gaps, and Hand-Off Problems 2
- Identification Errors 3
- Medical Complications 11
- Medication Safety 8
- Nonsurgical Procedural Complications 2
- Psychological and Social Complications 1
- Surgical Complications 7
- Family Members and Caregivers 2
- Health Care Executives and Administrators 56
- Health Care Providers 31
Non-Health Care Professionals
- Media 3
- Patients 15
- Australia and New Zealand 2
- Europe 5
- Canada 2
- United States of America 55
Search results for ""
Web Resource > Multi-use Website
Human Factors Engineering Team, Center for Devices and Radiological Health, Office of Communication, Education, and Radiation Programs (OCER), Division of Device User Programs and Systems Analysis (DDUPSA), 1350 Piccard Drive, HFZ-230, Rockville, MD 20850.
Human factors engineering (HFE) helps improve human performance and reduce the risks associated with use error. The U.S. Food and Drug Administration (FDA) works with manufacturers to ensure the application of HFE in the design of new products. In addition to providing information on these design issues, this site facilitates the reporting of unsafe incidents with medical devices.
Journal Article > Study
Shaw R, Drever F, Hughes H, Osborn S, Williams S. Qual Saf Health Care. 2005;14:279-283.
This study evaluated the utility of a voluntary reporting system from several National Health Service trusts. Investigators collected, categorized, and analyzed anonymized data from nearly 29,000 incidents, with the largest proportion related to falls. Discussion includes detailed presentation of the frequency of events, their location of occurrence, and the low rate of incidents associated with a catastrophic outcome. The authors conclude that this type of reporting system can provide useful information on a national level but requires the development of information technology systems to support the efforts.
Ebright PR, Rapala K. Indianapolis, IN: Center for Urban Policy and the Environment; September 2005:1-7.
This brief report discusses important issues for policy makers in developing a statewide incident reporting system.
Risk of electromagnetic interference with medical telemetry systems operating in the 460-470 MHz frequency bands.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; November 16, 2005.
This announcement notifies health care practitioners of possible interference with medical alarms and patient monitoring systems caused by mobile radio transmitters.
Rosenthal J, Booth M. Portland, ME: National Academy for State Health Policy; 2005.
This report, generated by the National Academy for State Health Policy, provides practical guidance and tools for states with existing reporting systems. The expert group that came together included data collectors, analysts, and users who aimed to develop strategies for improved collection, analysis, and feedback. The authors present key findings and emphasize that the quality improvement aspect of reporting systems is critical to success. Although the authors encourage greater use of reporting systems, a need exists for states to produce better-quality reports from their data to promote patient safety interventions. Additional initiatives from the report include development of a central Web-based repository of tools and resources that they plan to make available at their Web site.
Aspden P, Corrigan JM, Wolcott J, Erickson SM, eds for the Committee for Data Standards for Patient Safety, Institute of Medicine. Washington, DC: The National Academies Press; 2004. ISBN: 030909776.
Robust information systems serve as a backbone for both preventing medical error and learning from it. The authors submit that a national information infrastructure will facilitate immediate access to patient information and decision support mechanisms. They also suggest that a byproduct of the infrastructure will be a consistent method for managing patient safety data and the ability to capture it in real time as a result of care.
Legislation/Regulation > Organizational Policy/Guidelines
World Alliance for Patient Safety. Geneva, Switzerland: World Health Organization; 2005.
These guidelines present background on the development of incident reporting systems, list their functional elements, and provide suggestions for how to improve reporting system effectiveness.
Tools/Toolkit > Multi-use Website
Portland, ME: National Academy for State Health Policy.
This online toolkit provides sample documents, policies, and Web site links related to the 27 states that have implemented adverse event reporting initiatives.
Colburn D. The Oregonian. February 1, 2006:B1.
This article reports on the launch of Oregon's statewide voluntary incident reporting program to track medical error.
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.
Journal Article > Commentary
Feder HM. J Health Care Compliance. May/June 2006;8:49-50, 80.
This article briefly discusses the role of patient safety organizations (PSOs) as stipulated by the Patient Safety and Quality Improvement Act of 2005 and issues related to privacy, confidentiality, and impact on state reporting systems.
Harrisburg, PA: Patient Safety Authority. ISSN 1941-7144.
This quarterly newsletter shares insights and analysis on incident reports submitted through the Pennsylvania Patient Safety Reporting System.
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 > Commentary
Constitutional arguments in favor of modifying the HCQIA to allow the dissemination of physician information to healthcare consumers.
Chernitsky LA. Wash Lee Law Rev. Spring 2006;63:737-776.
The author presents a legal discussion on public access to physician information, arguing that Congress should allow consumers to access certain information while still protecting error information in order to promote error reporting.
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.
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.
Office of the Inspector General. Washington, DC: US Department of Health and Human Services; September 2006. Report No. OEI-09-04-00350.
This report presents findings from an investigation into the reporting of and response to restraint and seclusion-related deaths.
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.
Gulliver D. Sarasota Herald Tribune. November 7, 2006:BS1.
This article reports on the death of a restrained patient and outlines the factors affecting the subsequent reporting of the event.
Award > Award Recipient
Rabinowitz ABK, Clarke JR, Marella W, et al. Jt Comm J Qual Patient Saf. 2006;32:676-681.