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- Communication Improvement 2
- Culture of Safety 2
- Education and Training 4
- Error Reporting and Analysis 7
- Human Factors Engineering 5
- Legal and Policy Approaches 6
- Logistical Approaches 1
- Quality Improvement Strategies 5
- Specialization of Care 1
- Technologic Approaches 3
- Device-related Complications 5
- Diagnostic Errors 2
- Discontinuities, Gaps, and Hand-Off Problems 2
- Drug shortages 1
- Identification Errors 1
- Medical Complications 9
- Medication Safety
- Nonsurgical Procedural Complications 1
- Psychological and Social Complications 1
- Surgical Complications 6
- Surgery 2
- Nursing 2
- Pharmacy 4
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Journal Article > Commentary
Medication errors in family practice, in hospitals and after discharge from the hospital: an ethical analysis.
Clark PA. J Law Med Ethics. 2004;32:349-357.
In this article, the author urges the medical community to universally apply the systems approach to safety toward the reduction of medical errors. The author calls for health care to take medication errors more seriously and for patients to help drive improvement.
Journal Article > Study
Diagramming patients' views of root causes of adverse drug events in ambulatory care: an online tool for planning education and research.
Brown M, Frost R, Ko Y, Woosley R. Patient Educ Couns. 2006;62:302-315.
Berwick DM, Leape LL. Newsweek. October 16, 2006:70-71.
As part of the "Health for Life" series, Drs. Berwick and Leape discuss the notion of completely eliminating medical errors and share stories about several hospitals' efforts to raise safety standards.
Vonfremd M, Ibanga I. ABC News.com. July 10, 2008.
Several infants in a neonatal unit at a Texas hospital received overdoses of heparin. Authorities are investigating whether the error contributed to the deaths of two infants.
Audiovisual > Audiovisual Presentation
Spiesel S, Chadwick A. "Day to Day." National Public Radio. August 27, 2008.
This radio program discusses the results of a study on the risk of fatal medication errors involving prescribed medications taken at home.
Herper M, Lindner M. Forbes. August 25, 2008.
This article discusses common medical complications and care failures, and provides an annotated picture gallery of several hospital complications and how they can be prevented.
Tarkan L. New York Times. September 14, 2008;Health section:7.
This article describes how medical errors may cause serious harm in pediatric patients and offers tips for hospitals and parents to foster safe treatment.
Fillo KT. Bureau of Health Care Safety and Quality, Department of Public Health. Boston, MA: Commonwealth of Massachusetts; July 2018.
This report compiles patient safety data documented by Massachusetts hospitals. The latest numbers represent a modest decrease in serious reportable events recorded in acute care hospitals, from 1012 the previous year to 922. This presentation also includes events from ambulatory surgery centers. Previous years reports are also available.
May H. Salt Lake Tribune. June 26, 2009.
Rein L. Washington Post. July 21, 2009:E1.
This news article reports on Washington, DC–area initiatives to track preventable patient injury and discusses strategies to hold hospitals accountable to reduce the number of avoidable incidents.
Consumer Reports Health. September 2009.
Drawing from surveys of nurses and patients, this article offers tips on how to improve safety during a hospital stay.
Rockville, MD: Agency for Healthcare Research and Quality.
In this annual publication, AHRQ reviews the results of the National Healthcare Quality Report and National Healthcare Disparities Report. Providing a 5-year update on the National Quality Strategy, this report highlights that a wide range of quality measures have shown improvement in quality, access, and cost.
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.
Kowalczyk L. Boston Globe. September 21, 2011.
Reporting on a patient death involving alarm fatigue, this newspaper article describes how one hospital adopted aggressive measures to prevent similar incidents.
Audiovisual > Audiovisual Presentation
Faye J. NBC-17 News. November 10, 2011.
This news segment discusses how drug shortages can affect providers, patients, and decisions about medication therapy.
Kane J. PBS NewsHour. October 23, 2012.
This video reveals how checklists can help patients and their families ensure safety during hospital care.
Valencia MJ. Boston Globe. March 10, 2011.
This newspaper article reports on a fatal medication error involving an anticoagulant overdose.
Lucado J, Paez K, Elixhauser A. HCUP Statistical Brief #109. Rockville, MD: Agency for Healthcare Research and Quality; April 2011.