Narrow Results Clear All
- Communication Improvement 27
- Culture of Safety 5
- Education and Training 8
- Error Reporting and Analysis 17
- Human Factors Engineering 9
- Legal and Policy Approaches 12
- Logistical Approaches 4
- Quality Improvement Strategies 11
- Teamwork 3
- Technologic Approaches 7
- Transparency and Accountability 1
- Device-related Complications 3
- Diagnostic Errors 2
- Discontinuities, Gaps, and Hand-Off Problems 5
- Identification Errors
- Medical Complications 9
- Medication Safety 12
- Nonsurgical Procedural Complications 2
- Psychological and Social Complications 2
- Surgical Complications 27
- Transfusion Complications 1
- Family Members and Caregivers 3
- Health Care Executives and Administrators 22
Health Care Providers
- Nurses 4
- Non-Health Care Professionals 11
Search results for ""
Cases & Commentaries
- Web M&M
Tejal K. Gandhi, MD, MPH; October 2003
Switched urine specimens lead to a patient receiving the wrong answer about her pregnancy test.
Tools/Toolkit > Fact Sheet/FAQs
Rockville, MD: Agency for Healthcare Research and Quality; October 2001. AHRQ Publication No. 01-0017.
A brief presentation of "pearls" to allow consumers to take an active role in preventing medical errors.
Web Resource > Multi-use Website
Oakbrook Terrace, IL: Joint Commission.
This campaign provides sets of materials to enable patients and families to engage in making their health care experiences as safe as possible. Topics covered include safe surgery, pain management, medication safety, and most recently, infection prevention. Each topical package includes infographics, videos, instruction guides, and a podcast.
Scobie S, Thomson R. London, England: National Patient Safety Agency; 2005.
Created in 2001 to institute changes in health care across the United Kingdom, the National Patient Safety Agency (NPSA) presents their first report of patient safety incidents. The two-part report begins with a general discussion of incident reporting, the basis for a national reporting system, and the development of the Patient Safety Observatory. The second part builds on this framework by discussing how the acquired data can be used and translated into safer health care strategies. The report itself encompasses more than 85,000 collected incident reports with analysis, comparisons, and case studies to illustrate important safety issues for future efforts. This represents the first of a series of expected reports from NPSA on patient safety data to be published.
BBC News. August 9, 2005.
This article reports on a prototype electronic wristband that checks medications against a patient's prescription.
Journal Article > Study
Gray JE, Suresh G, Ursprung R, et al. Pediatrics. 2006;117:e43-e47.
This study demonstrated that more than half of the patients in a single neonatal intensive care unit are at risk for misidentification errors due to similarities in patient names or medical record numbers.
Gray R. Scotland on Sunday. January 8, 2006.
This story discusses the impact of a computer glitch in a system used by more than 80% of general practitioners in Scotland. In addition to physician notes being inadvertently attached to the wrong patient's medical record, reports suggest that some patients actually received incorrect prescriptions due to printing errors caused by the system.
Tools/Toolkit > Fact Sheet/FAQs
American College of Surgeons.
This brochure provides information for patients to help ensure that their surgery is performed on the correct part of the body.
Legislation/Regulation > Multi-use Website
The Joint Commission.
According to an AHRQ-supported study, wrong-site surgery occurred at a rate of approximately 1 per 113,000 operations between 1985 and 2004. In July 2004, The Joint Commission enacted a Universal Protocol that was developed through expert consensus on principles and steps for preventing wrong-site, wrong-procedure, and wrong-person surgery. The Universal Protocol applies to all accredited hospitals, ambulatory care, and office-based surgery facilities. The protocol requires performing a time out prior to beginning surgery, a practice that has been shown to improve teamwork and decrease the overall risk of wrong-site surgery. This Web site includes a number of resources and facts related to the Universal Protocol. Wrong-site, wrong-procedure, and wrong-patient errors are all now considered never events by the National Quality Forum and sentinel events by The Joint Commission. The Centers for Medicare and Medicaid Services have not reimbursed for any costs associated with these surgical errors since 2009.
Davis R. USA Today. April 17, 2006.
This article reports on a recent AHRQ-funded study on the incidence of wrong-site surgery and shares various perspectives on the issue.
Bernhard B. The Orange County Register. April 19, 2006.
This article reports on an Anaheim anesthesiologist's pre-surgery checklist, inspired by similar checklists used in the aviation industry.
Journal Article > Study
Waterman AD, Gallagher TH, Garbutt J, Waterman BM, Fraser V, Burroughs TE. J Gen Intern Med. 2006;21:367-370.
This AHRQ–funded study used more than 2000 telephone interviews with recently discharged patients to demonstrate that patients who are most comfortable with error prevention were more likely to take specific action compared to those who are less comfortable. The authors report that although the majority of patients expressed comfort in asking questions about medications and general medical questions, far fewer actively engaged in marking their incision site or asking about handwashing. A past study discussed how to improve patients' perceptions of safety in hospitals, including educational interventions that might empower patients to take greater preventive action, as outlined in this study.
Feldman R. The Washington Post. May 2, 2006:HE01.
In this article, a nurse shares her firsthand account of what it was like to be a surgical patient and the surprising safety and quality shortcomings she encountered during her hospital stay.
Edozien L. Saferhealthcare. June 2, 2006.
This article discusses how misidentification can occur in the medical environment and provides several illustrations of its negative consequences.
Bramson K, Mooney T. Providence Journal. August 18, 2006.
This article reports on a case of mistaken identity that resulted in erroneous surgery, despite a "time out" before beginning the operation.
Kapadia R. Smart Money. October 2006;15:112-114.
This article provides tips for consumers to help keep their hospital care as safe and hassle-free as possible.
East Perth, WA, Australia: Department of Health of Western Australia; 2006.
This report shares the 2005-2006 results of Western Australia's sentinel event reporting program and documents a reduction in two types of events: wrong site/wrong part surgeries and retained foreign objects.
Journal Article > Commentary
The author explains the Joint Commission on Accreditation of Healthcare Organizations' Universal Protocol on surgical site verification in the context of its implementation in a New Jersey hospital.
St. Paul, MN: Minnesota Department of Health; March 2019.
The National Quality Forum has defined 29 never events—patient safety problems that should never occur, such as wrong-site surgery and patient falls. Since 2003, Minnesota hospitals have been required to report such incidents. The 2018 report summarizes information about 384 adverse events that were reported and found pressure ulcers and invasive procedure events increased, while fall-related deaths decreased. Reports from previous years are also available.
St. Paul, MN: Minnesota Department of Health; January 2009.
This report provides background on the Minnesota Never Events reporting initiative, tips for patients on how to receive the safest care possible, and a table of events reported by all hospitals in the state.