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Perspectives on Safety > Perspective
Organizational Change in the Face of Highly Public Errors—I. The Dana-Farber Cancer Institute Experience
with commentary by James B. Conway; Saul N. Weingart, MD, PhD, Errors in the Media and Organizational Change, May 2005
A decade ago, two tragic medical errors rocked one of the world’s great cancer hospitals, Dana-Farber Cancer Institute (DFCI) in Boston, to its core. The errors led to considerable soul searching and, ultimately, a major change in institutional practices a...
Legislation/Regulation > Federal Legislation
S 1337, 109th Cong, 1st Sess (Mt 2005).
This bill was introduced in the U.S. Senate to encourage alternatives to the current medical malpractice system (by creating a "health care court") and to promote early disclosure and resolution of medical errors.
USA Today. July 4, 2005.
This editorial supports legislation such as the Fair and Reliable Medical Justice Act, which calls for special courts to evaluate medical malpractice cases.
Wolosin R, Vercler L, Matthews J. Patient Safety & Quality Healthcare. November/December 2005;2:40-44.
The authors examined patients' perceptions of safety in hospital settings and factors that affect their perceptions.
Edmonton, AB: Canadian Patient Safety Institute; December 2, 2005.
This news release announces the selection of 28 research and demonstration projects eligible for funding from the Canadian Patient Safety Institute research initiative.
Journal Article > Commentary
Clinton HR, Obama B. N Engl J Med. 2006;354:2205-2208.
This commentary is written by Senators Hillary Rodham Clinton (D-NY) and Barack Obama (D-IL), who coauthored the National Medical Error Disclosure and Compensation (MEDiC) Act. Providing context for the bill, the senators advocate for necessary improvements in patient safety and the medical liability environment through a series of important and interdependent strategies. These include reducing the rates of preventable patient injuries, promoting open communication between physicians and patients, ensuring patients' access to fair compensation for legitimate medical injuries, and reducing liability insurance premiums for providers. The senators further discuss the implications of each approach and specifically outline the major provisions of the bill, including how it will foster and promote the necessary improvement efforts.
Journal Article > Study
Stebbing C, Kaushal R, Bates DW. Pediatrics. 2006;117:1907-1914.
This study analyzed newspaper coverage of pediatric medication errors and adverse drug events in five countries to demonstrate increased interest in the topic over the past decade. Investigators examined the number of articles and the types of events covered and assessed the overall themes presented and framed by the media. The majority of articles published covered patient incidents followed by policy and then research in decreasing order of frequency. Despite the occasional occurrence of sensational reporting on errors, more than 70% of articles that were deemed to be negatively associated with patient safety were covered in a neutral manner.
Journal Article > Commentary
Emanuel EJ. JAMA. 2007;297:2131-2133.
The author discusses how changes in language used to describe health care reflect a shifting public perception of the US health care system. This shift involves increasing recognition that errors do occur and that the health care system is flawed.
Award > Award Recipient
Horsham, PA: Institute for Safe Medication Practices; November 7, 2008.
The Cheers awards annually recognize leaders in the field of medication safety. Among the 2008 honorees are FDA Patient Safety News; the Health Information Translations development consortium, Mount Carmel Health System, OhioHealth, The Ohio State University Medical Center, and Nationwide Children's Hospital; the Sebastian Ferrero Foundation; Debora Simmons, RN, MSN; and Diane Cousins, RPh.
The Joint Commission.
The Eisenberg Award honors individuals and organizations who have made vital accomplishments in improving patient safety and quality. The 2009 honorees are Gary Kaplan, MD; Tejal Gandhi, MD; The Keystone Center for Patient Safety; Mercy Hospital Anderson (Cincinnati, Ohio); and Noreen Zafar, MD.
Journal Article > Study
de Saint Maurice G, Auroy Y, Vincent C, Amalberti R. Qual Saf Health Care. 2010;19:327-331.
This study tracked adoption of a process-oriented safety rule and found that compliance eroded over time, with a major trigger being lack of compliance by a senior staff member. The authors provide caution about the role of policies to promote safety behaviors, particularly if such policies are not prioritized by staff as important.
Austin, TX: Texas Medical Institute for Technology and the Quaid Foundation; 2010.
This documentary reports on families affected by medical errors; it includes the story of a high-profile heparin overdose and how it transformed the family of actor Dennis Quaid into advocates for patient safety.
ISMP Medication Safety Alert! Acute Care Edition. October 18, 2012;17:1-4.
This piece reviews risks associated with the use of compounding pharmacies and recommends that legislative oversight can improve medication safety.
Joint Commission. February 6, 2013.
The Eisenberg Award honors individuals and organizations who have made vital accomplishments in improving patient and quality. The 2012 honorees are Saul Weingart, MD, PhD; Kaiser Permanente, Oakland, California; and Memorial Hermann Healthcare System, Houston, Texas. The awards will be presented at the National Quality Forum's Annual Conference on March 8, 2013, in Washington, DC.
Clark C. HealthLeaders Media. September 13, 2013.
This news piece highlights concern around the safety of elective premature deliveries and describes techniques organizations have used to prevent such procedures.
Joint Commission. January 27, 2014.
The Eisenberg Award honors individuals and organizations who have made vital accomplishments in improving patient and quality. The 2013 honorees are Institute for Clinical Systems Improvement, Minnesota Hospital Association, and Stratis Health, from Minnesota; Anthem Blue Cross, National Health Foundation, Hospital Association of Southern California, Hospital Association of San Diego & Imperial Counties, and the Hospital Council of Northern & Central California, from California; Vidant Health, of North Carolina; and Gail L. Warden, in Michigan. The awards were presented at the National Quality Forum's Annual Conference on February 13, 2014, in Washington, DC.