Narrow Results Clear All
- Communication Improvement 2
- Culture of Safety 3
- Education and Training 2
- Error Reporting and Analysis
- Legal and Policy Approaches 5
- Quality Improvement Strategies
- Teamwork 1
- Technologic Approaches 2
- Device-related Complications 4
- Diagnostic Errors 1
- Discontinuities, Gaps, and Hand-Off Problems 2
- Medical Complications 4
- Medication Errors/Preventable Adverse Drug Events 3
- Surgery 1
- Nursing 1
- Pharmacy 1
Search results for ""
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.
FDA preliminary public health notification: update of information about Ralstonia spp. associated with Vapotherm Respiratory Gas Administration device.
Schultz DG. Rockville, MD: Center for Devices and Radiological Health, Food and Drug Administration; December 20, 2005.
This safety alert for health care practitioners discusses bacterial contamination of gas devices and recommends alternatives be used until the source of the contamination is identified.
Journal Article > Study
Freer Y, Lyon A. Arch Dis Child Fetal Neonatal Ed. 2006;91:F327-F329.
The authors found that clinicians were not likely to alter their practice in response to adverse incident alerts if the recommended change was not supported by evidence. A related editorial ties this finding to the need for timely patient safety improvement.
Office of the Inspector General. Washington, DC: US Department of Health and Human Services; September 2006. Report No. OEI-09-04-00350.
This report presents findings from an investigation into the reporting of and response to restraint and seclusion-related deaths.
Falls Church, VA: TRICARE Management Activity, Office of the Assistant Secretary of Defense; 2006.
Web Resource > Government Resource
Indiana State Department of Health.
This Web site provides background and information on Indiana's statewide incident reporting initiative.
Legislation/Regulation > Pennsylvania Legislation
General Assembly of Pennsylvania. SB968 (2007).
This bill requires that Pennsylvania hospitals and nursing homes implement an internal infection control plan and report hospital-acquired infections.
Gould M. Health Service Journal. September 15, 2008:22-24.
This article describes the state of general practitioner incident reporting in the United Kingdom.
Health-Care-Associated Infections in Hospitals: An Overview of State Reporting Programs and Individual Hospital Initiatives to Reduce Certain Infections.
Washington, DC: United States Government Accountability Office; September 2008. Publication GAO-08-808.
This report describes state reporting programs for health care–associated infection (HAI), hospital initiatives to reduce MRSA (methicillin-resistant Staphylococcus aureus), and challenges encountered in HAI reduction.
The High Costs of Weak Compliance With the New York State Hospital Adverse Event Reporting and Tracking System.
Thompson WC Jr. New York, NY: Office of the New York City Comptroller, Office of Policy Management; 2009.
This report assesses the New York State Department of Health's New York Patient Occurrence and Tracking System (NYPORTS). It observes trends of adverse event reporting, finds that New York City hospitals report dramatically fewer events per discharge, explores reasons for underreporting, and discusses the impact on safety improvement efforts.
Salt Lake City, UT: Utah Department of Health, Utah Hospitals & Health Systems Association, and HealthInsight; March 10, 2010.
This brief provides information on 101 sentinel events reported to the state of Utah in 2009. The report also includes background on efforts to address such incidents.
Valencia MJ. Boston Globe. March 10, 2011.
This newspaper article reports on a fatal medication error involving an anticoagulant overdose.
Web Resource > Government Resource
National Patient Safety Agency.
This Web site provides data on safety incidents from the United Kingdom in the form of workbooks sorted by either organization or region.
Journal Article > Study
Greene SB, Williams CE, Pierson S, Hansen RA, Carey TS. J Patient Saf. 2011;7:92-98.
All North Carolina nursing homes are required to report medication error data. This study reports on a pilot effort to feed back data on error rates to individual nursing homes.
Journal Article > Commentary
Public reporting of health care–associated surveillance data: recommendations from the Healthcare Infection Control Practices Advisory Committee.
Talbot TR, Bratzler DW, Carrico RM, et al; Healthcare Infection Control Practices Advisory Committee. Ann Intern Med. 2013;159:631-635.
Jefferson City, MO: Center for Patient Safety; June 11, 2019.
Patient Safety Organizations (PSOs) provide local evidence to inform learning at the state level. This annual report analyzes trends present in reports submitted to the PSO in 2018. Medication errors, falls, and health care–acquired infections were frequently reported. The material discusses reasons for these events, shares lessons learned, and points to resources to aid organizations in reducing conditions that enable reportable occurrences.
Journal Article > Study
Partnering with VA stakeholders to develop a comprehensive patient safety data display: lessons learned from the field.
Chen Q, Shin MH, Chan JA, et al. Am J Med Qual. 2016;31:178-186.
This study reports the development of a comprehensive patient safety tool for Veterans Administration medical centers, with input from frontline stakeholders, to integrate data sources including incident reports, AHRQ Patient Safety Indicators, and other quality measures related to safety in a single location in order to facilitate collaboration at local sites.
Healthcare Inspection: Evaluation of the Veterans Health Administration's National Consult Delay Review and Associated Fact Sheet.
Daigh JD Jr. Washington, DC: VA Office of the Inspector General; December 15, 2014. Report No. 14-04705-62.
Misrepresentation of findings, either by accident or design, can result in ineffective use of resources and poor decision-making. This investigation found inconsistencies in the information reported by the Veterans Health Administration in the widely-publicized analysis discussing weaknesses in the organization that resulted in delayed care. The author calls for the assessment to be revisited to ensure conclusions and work toward improvement are verifiable to augment the safety and timeliness of care provided to veterans.
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; January 2015. Report No. OEI-01-13-00400.
A widely-reported meningitis outbreak in the United States uncovered quality and safety issues associated with the use of compounded sterile preparations. This publication describes an analysis of five accreditation organizations and their ability to provide oversight and inspection of Medicare hospitals that contract with compounding entities. The authors offer recommendations to help hospitals determine if their compounded sterile preparations contracts ensure products are prepared safely for use, including targeted training for surveyors related to compounding and improved contracting processes.
Department of Health. London, England: Crown Publishing; February 2015. ISBN: 9781474112116.
The Francis inquiry uncovered numerous problems in the National Health Service and led to many commentaries about improvement strategies. Summarizing achievements in applying recommendations following the inquiry, this report outlines where further work is needed to ensure that advances in safe care delivery are sustained. Companion materials available include an analysis exploring equality considerations and a table revealing the government response and progress for each of the 290 recommendations put forth in the original inquiry.