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- Communication Improvement 4
- Culture of Safety 1
- Education and Training 5
- Error Reporting and Analysis 13
- Human Factors Engineering 2
- Legal and Policy Approaches 3
- Logistical Approaches 2
- Quality Improvement Strategies 2
- Teamwork 1
- Technologic Approaches 4
- Device-related Complications 2
- Identification Errors 4
- Medical Complications 5
- Medication Errors/Preventable Adverse Drug Events 6
- Psychological and Social Complications 1
- Surgical Complications 5
- Transfusion Complications 1
- Australia and New Zealand 2
- Europe 5
- Canada 1
Search results for "Government Resource"
- Government Resource
- Epidemiology of Errors and Adverse Events
St. Paul, MN: Minnesota Department of Health; March 2019.
The National Quality Forum has defined 29 never events—patient safety problems that should never occur, such as wrong-site surgery and patient falls. Since 2003, Minnesota hospitals have been required to report such incidents. The 2018 report summarizes information about 384 adverse events that were reported and found pressure ulcers and invasive procedure events increased, while fall-related deaths decreased. Reports from previous years are also available.
Whitson T, Garten B. Indianapolis, IN: Indiana State Department of Health; 2017.
Sixth Report of Session 2008–09. House of Commons Health Committee. London, England: The Stationery Office; July 3, 2009. Publication HC 151-I.
This government report analyzes the National Health Service's efforts to enhance patient safety and recommends improving certain areas, such as adopting technology, analyzing failure, and ensuring both practitioner education and adequate staffing.
PA-PSRS Patient Saf Advis. June 2009;6:39-45.
This piece identifies risk factors associated with retention of foreign objects and suggests several tactics to prevent its occurrence.
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.
Adverse Events in Hospitals: Care Study of Incidence Among Medicare Beneficiaries in Two Selected Counties.
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; December 2008. Report No. OEI-06-08-00220.
The Center for Medicare and Medicaid Services (CMS) no longer reimburses hospitals for the costs associated with certain preventable adverse events, many (but not all) of which are considered never events. This report from the federal Office of the Inspector General (OIG) examines the adverse events in a sample of Medicare beneficiaries. As outlined in a previous report, the OIG chose to evaluate the overall incidence of adverse events, including "no pay for errors" conditions, never events, and all other adverse consequences of hospitalization, including non-preventable adverse events. Therefore, the 15% overall incidence of adverse events found in this study should be interpreted with caution. Less than 1% of patients experienced a never event, and approximately 4% experienced a condition on CMS's no pay for errors list.
Office of the Inspector General. Washington, DC: US Department of Health and Human Services; September 2008. Report No. OEI-02-08-00140.
This report summarizes 2007 data on quality and safety issues in Medicare- and Medicaid-certified nursing homes and finds that 17% of the organizations were cited for care deficiencies that could result in harm to residents.
Web Resource > Government Resource
Indiana State Department of Health.
This Web site provides background and information on Indiana's statewide incident reporting initiative.
Wilkins K, Shields M. Ottawa, Canada: Statistics Canada; May 2008. Catalogue no. 82-003-X Health Reports.
This report describes results of a large survey of Canadian nurses and identifies work-related factors that contribute to medication errors.
Victorian Auditor-General's Office. Melbourne, Australia: Victorian Government Printer; 2008. ISBN: 1921060689.
This report examined patient safety in public hospitals in the state of Victoria (Australia), which does not have an incident monitoring system. Estimating that 10% of patients experienced a medical error, the report recommends several steps to improve safety.
Journal Article > Government Resource
Acute Hepatitis C virus infections attributed to unsafe injection practices at an endoscopy clinic—Nevada, 2007.
Centers for Disease Control and Prevention. MMWR Morb Mortal Wkly Rep. 2008;57:513-517.
This report further discusses the investigation of a Hepatitis C outbreak that resulted from unsafe injection practices at an endoscopy clinic.
National Patient Safety Agency. London, UK: National Health Service.
These documents summarize National Patient Safety Agency incident reporting data from the first year of data collection. They are accompanied by workbooks for data review, slide sets and trends analysis.
Fifty-first Report of Session 2005-06. House of Commons Committee on Public Accounts. London, England: The Stationary Office; July 6, 2006. Publication HC 831.
PA-PSRS Patient Saf Advis. May 2007;4(suppl 2):1-8.
This article shares findings from a workgroup that assessed the efficacy of pharmacy computer systems in detecting unsafe medication orders. The 30 Pennsylvania hospitals that participated in the workgroup found that their systems were not catching all unsafe orders.
Elixhauser A, Owens P. HCUP Statistical Brief #29. Rockville, MD: Agency for Healthcare Research and Quality; April 2007.
This report presents data on adverse drug events from the Healthcare Cost and Utilization Project, including information on adverse effects and drug misadministration.
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.
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.
Center for Devices and Radiological Health. Bethesda, MD: Food and Drug Administration, US Dept of Health and Human Services; 2006.
This document provides background on hospital bed injuries, identifies potentially dangerous design flaws, and offers assessment tools to reduce entrapment incidents.
Journal Article > Government Resource
Centers for Disease Control and Prevention. MMWR Morb Mortal Wkly Rep. January 13, 2006;55:1-5.
This study reports on the incidence of unintentional exposure to prescription and over-the-counter medications that are not properly stored out of reach of young children.
Scobie S, Thomson R. London, England: National Patient Safety Agency; 2005.
Created in 2001 to institute changes in health care across the United Kingdom, the National Patient Safety Agency (NPSA) presents their first report of patient safety incidents. The two-part report begins with a general discussion of incident reporting, the basis for a national reporting system, and the development of the Patient Safety Observatory. The second part builds on this framework by discussing how the acquired data can be used and translated into safer health care strategies. The report itself encompasses more than 85,000 collected incident reports with analysis, comparisons, and case studies to illustrate important safety issues for future efforts. This represents the first of a series of expected reports from NPSA on patient safety data to be published.