Narrow Results Clear All
- Communication Improvement 2
- Education and Training 4
- Error Reporting and Analysis 6
- Human Factors Engineering 1
- Legal and Policy Approaches
- Quality Improvement Strategies 2
- Teamwork 1
- Technologic Approaches 2
- Discontinuities, Gaps, and Hand-Off Problems 1
- Identification Errors 3
- Medical Complications 2
- Medication Safety 1
- Psychological and Social Complications 2
- Surgical Complications
Search results for ""
Journal Article > Commentary
Watson DS. AORN J. 2006;84:273-275.
The author discusses recommended policies and practices for minimizing the risk of retained foreign objects.
McCarty JF. Plain Dealer. January 16, 2007:A1.
This article reports on an incident of a retained foreign object discovered years after a patient's death, as well as the subsequent lawsuit.
Kowalczyk L. Boston Globe. October 26, 2007;Metro section:1A.
This article investigates the causes of surgical errors reported in recent years by Massachusetts hospitals, and identifies team training and instrument bar-coding as solutions for improvement.
Journal Article > Commentary
Pronovost PJ, Goeschel CA, Wachter RM. JAMA. 2008;299:2197-2199.
In October 2008, Medicare will put into effect a new policy that withholds payment for eight preventable complications of care, with plans already in place to expand this list in 2009. This initiative has prompted several discussions in the safety community, ranging from the business case for adopting such a policy to whether any of the targeted conditions can be accurately identified as present on admission. This commentary further explores the basis of Medicare's efforts and focuses on criteria that should be considered when withholding payment for complications of care. The authors provide a framework that requires each proposed complication to be important, measurable, and truly preventable to meet the burden of proof for inclusion. Only foreign objects retained after surgery and catheter-related blood stream infections serve as "wise and just" complications based on their assessment. While the authors acknowledge the opportunity for Medicare to align payment incentives and stimulate improvements in quality and reduce costs, they caution against rapid adoption and a failure to carefully evaluate the benefits and risks of the initiative.
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.
Journal Article > Study
Cima RR, Kollengode A, Storsveen AS, et al. Jt Comm J Qual Patient Saf. 2009;35:123-132.
Altman LK. New York Times. December 11, 2001;1:1.
This news piece reports on wrong-site and wrong-patient surgery and describes efforts to prevent surgical errors following a Joint Commission sentinel event alert on the topic.
Eisler P. USA Today. March 8, 2013.