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Journal Article > Study
Shaw R, Drever F, Hughes H, Osborn S, Williams S. Qual Saf Health Care. 2005;14:279-283.
This study evaluated the utility of a voluntary reporting system from several National Health Service trusts. Investigators collected, categorized, and analyzed anonymized data from nearly 29,000 incidents, with the largest proportion related to falls. Discussion includes detailed presentation of the frequency of events, their location of occurrence, and the low rate of incidents associated with a catastrophic outcome. The authors conclude that this type of reporting system can provide useful information on a national level but requires the development of information technology systems to support the efforts.
Risk of electromagnetic interference with medical telemetry systems operating in the 460-470 MHz frequency bands.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; November 16, 2005.
This announcement notifies health care practitioners of possible interference with medical alarms and patient monitoring systems caused by mobile radio transmitters.
Rosenthal J, Booth M. Portland, ME: National Academy for State Health Policy; 2005.
This report, generated by the National Academy for State Health Policy, provides practical guidance and tools for states with existing reporting systems. The expert group that came together included data collectors, analysts, and users who aimed to develop strategies for improved collection, analysis, and feedback. The authors present key findings and emphasize that the quality improvement aspect of reporting systems is critical to success. Although the authors encourage greater use of reporting systems, a need exists for states to produce better-quality reports from their data to promote patient safety interventions. Additional initiatives from the report include development of a central Web-based repository of tools and resources that they plan to make available at their Web site.
Aspden P, Corrigan JM, Wolcott J, Erickson SM, eds for the Committee for Data Standards for Patient Safety, Institute of Medicine. Washington, DC: The National Academies Press; 2004. ISBN: 030909776.
Robust information systems serve as a backbone for both preventing medical error and learning from it. The authors submit that a national information infrastructure will facilitate immediate access to patient information and decision support mechanisms. They also suggest that a byproduct of the infrastructure will be a consistent method for managing patient safety data and the ability to capture it in real time as a result of care.
Colburn D. The Oregonian. February 1, 2006:B1.
This article reports on the launch of Oregon's statewide voluntary incident reporting program to track medical error.
Journal Article > Study
The limits of knowledge management for UK public services modernization: the case of patient safety and service quality.
Currie G, Waring J, Finn R. Public Admin. 2008;86:363-385.
This article analyzes the implementation of the United Kingdom's error reporting system, the National Reporting and Learning System, and addresses the cultural conflicts between physicians, nurses, and managers inherent in implementing such a system.
Journal Article > Commentary
Jha AK, Classen DC. N Engl J Med 2011;365:1756-1758.
Describing weaknesses in current safety measurement tools, this perspective suggests that legislation requiring use of electronic medical records can improve safety in health care.
Technical Evaluation, Testing, and Validation of the Usability of Electronic Health Records: Empirically Based Use Cases for Validating Safety-Enhanced Usability and Guidelines for Standardization.
Lowry SZ, Ramaiah M, Taylor S, et al. Gaithersburg, MD: US Department of Commerce, National Institute of Standards and Technology; October 2015. NISTIR 7804-1.
Unintended consequences associated with usability of electronic health record (EHR) systems have the potential to negatively affect patient safety. This report outlines standards to enhance safety-related usability of EHRs by identifying root causes of use errors and addressing these weaknesses through human factors design.