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- Error Reporting and Analysis 3
- Human Factors Engineering 2
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- Quality Improvement Strategies 1
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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.
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.
Journal Article > Commentary
Smith SW. N Engl J Med. 2007;10:960-963.
In this perspective, the author discusses how the organizational culture of the US Food and Drug Administration (FDA) must change to foster a culture of safety.
Tools/Toolkit > Fact Sheet/FAQs
FDA Consumer Health Information. Rockville, MD: US Food and Drug Administration; February 20, 2009.
This fact sheet discusses the role of the Food and Drug Administration (FDA) in reducing medication errors and describes examples of such errors for consumers.
Smith S. Boston Globe. June 19, 2008;Metro section:1B
Massachusetts government and state insurers have outlined policies whereby they will not reimburse hospitals for care related to 28 preventable errors, though they have not specified details about implementation or enforcement.
Journal Article > Commentary
Leary E, Diers D. Yale J Biol Med. 2013;86:79-87.
This commentary describes unsafe practices that resulted in the spread of an infectious disease and highlights how poor whistleblower protection prevented employees from speaking up.
Journal Article > Study
Meara E, Horwitz JR, Powell W, et al. N Engl J Med. 2016;375:44-53.
Growing rates of opioid misuse endanger public health. The impact of legal restrictions to limit high-risk prescribing and resultant adverse events is unclear. One recent study found that opioid-related adverse events were effectively reduced in states with stringent prescription drug monitoring programs compared to states without such regulations. However, this study examined data regarding Medicare beneficiaries with disabilities before and after adoption of controlled-substance laws and found no significant decrease in rates of nonfatal overdose, high opioid doses, or receipt of opioids from four or more prescribers. These results suggest that current regulatory policy may not be sufficient to address high-risk prescribing practices among Medicare beneficiaries with disabilities. More work is needed to develop effective strategies to treat chronic pain safely in this high-risk population. A WebM&M commentary described risks related to prescribing opioids for patients with chronic pain.