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- Communication Improvement 2
- Culture of Safety 2
- Education and Training 3
- Error Reporting and Analysis 5
- Legal and Policy Approaches 6
- Logistical Approaches 1
- Quality Improvement Strategies 4
- Technologic Approaches 1
- Device-related Complications 3
- Diagnostic Errors 1
- Discontinuities, Gaps, and Hand-Off Problems 2
- Identification Errors 9
- Medical Complications
- Medication Safety 5
- Psychological and Social Complications 1
- Surgical Complications
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Cases & Commentaries
- Web M&M
Andre R. Campbell, MD; April 2003
Laparoscopic colostomy completed in reverse induces total bowel obstruction.
Perspectives on Safety > Perspective
with commentary by Ashish K. Jha, MD, MPH, The Transformation of Patient Safety at the VA, September 2006
Five years after the landmark Crossing the Quality Chasm report by the Institute of Medicine (IOM), the quality and safety of health care in the United States remains far from ideal.(1) It is easy to feel pessimistic. Can health care organizations really...
Journal Article > Study
Chan DK, Gallagher TH, Reznick R, Levinson W. Surgery. 2005;138:851-858.
This study evaluated the capacity of 30 academic surgeons to discuss error scenarios, such as wrong-side surgery and retained sponges, with standardized patients. Investigators analyzed the conversations and discovered that 57% of the surgeons used the word "error" or "mistake," but less than half offered a verbal apology. The authors conclude that significant gaps exist between how physicians disclose medical errors and what patients expect in such conversations, thereby generating a need for educational intervention. The same authors previously wrote a commentary calling for professional action in disclosure of medical errors.
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.
Oakbrook Terrace, IL: The Joint Commission; March 2007.
This report reveals that the overall quality of care delivered by US hospitals improved steadily between 2003 and 2005, as measured by adherence to evidence-based treatments for myocardial infarction, congestive heart failure, and pneumonia. Adherence to the Joint Commission's National Patient Safety Goals, which include measures to prevent wrong-site surgery and promote medication reconciliation, was also measured. Although results on these measures showed a more mixed picture, the report cautions that changes in measurement during the study period limit interpretability of the results.
Herper M, Lindner M. Forbes. August 25, 2008.
This article discusses common medical complications and care failures, and provides an annotated picture gallery of several hospital complications and how they can be prevented.
National Priorities Partnership. Washington, DC: National Quality Forum; 2008. ISBN: 1933875194.
This report resulted from a consensus program involving 28 national organizations that sought to outline goals for improving the US health care system and share examples of such efforts in patient safety and other identified areas.
National Patient Safety Agency. London, UK: National Reporting and Learning Service; 2009.
This report from the United Kingdom is intended to guide Primary Care Trusts in implementing never events policies for 2009-2010.
Web Resource > Multi-use Website
The Joint Commission.
The Joint Commission has traditionally focused on accreditation of health care organizations and, through its Joint Commission Resources arm, on quality improvement (QI) in areas related to its accreditation functions. In the first major initiative under the leadership of new president Dr. Mark Chassin, The Joint Commission launched this Center, which will focus on applying rigorous QI methods to improve safety in a number of challenging areas (the first three are hand hygiene, handoff communication, and preventing wrong site surgery) and disseminating the lessons from these efforts. This Web site provides more information about the Center and its goals.
Journal Article > Review
Cao LY, Taylor JS, Vidimos A. Dermatol Online J. 2010;16:3.
This review examines numerous safety issues relevant to outpatient dermatology practice, including medication errors, diagnostic errors, office-based surgery, wrong-site procedures, and laser safety.
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.