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A Consensus Statement of the Harvard Hospitals. Burlington: Massachusetts Coalition for the Prevention of Medical Errors; 2006.
This consensus paper of the Harvard-affiliated hospitals was prepared by clinicians, risk managers, and patients to provide an in-depth understanding of preventable adverse events, their impact on patients, families, and providers, and how to manage such events. The report provides detailed guidelines based on the premise that all care should be safe and patient-centered and that all actions require full disclosure. In addition to offering recommendations on how to effectively communicate with patients and families, the report discusses support for caregivers and a detailed strategy for institutions to respond to such events in a timely and appropriate fashion. Finally, the comprehensive report offers several appendices that include recommendations and a case study on communicating with patients and families.
Journal Article > Commentary
Wachter RM, Pronovost PJ. N Engl J Med. 2009;361:1401-1406.
An early focus of the patient safety movement was a shift from the traditional culture of individual blame to one that investigated errors as the failure of systems, popularized by adoption of James Reason's Swiss cheese model of organizational accidents. In recent years, there has been some backlash against a unidimensional systems-focused model, with past commentaries exploring the tension between a "no blame" culture and individual accountability. Articles in this genre have considered this tension in the educational setting, and a popular construct involves a just culture framework, which differentiates "no blame" from blameworthy acts. This commentary, written by two of the leaders in the safety field, further explores the relationship between blame and accountability, discusses why enforcement of safety standards tends to be lax (particularly in cases involving physicians), and proposes a working balance that not only promotes a safety culture but also safe patient care. The authors highlight hand hygiene non-compliance as an example of a behavior that should be managed through an accountability framework, with providers held accountable for failure to adhere to a known safety standard. They also offer suggested penalties (mostly involving suspension of clinical privileges) for repeated failures to comply with hand hygiene and other established safe practices.
Tools/Toolkit > Fact Sheet/FAQs
Washington, DC: National Priorities Partnership and National Quality Forum; December 2010.
This briefing sheet reviews the opportunities, solutions, and drivers for medication safety improvements.