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Journal Article > Study
Levtzion-Korach O, Alcalai H, Orav EJ, et al. J Patient Saf. 2009;5:9-15.
The limitations of standard incident reporting systems have been well documented. Although ubiquitous and relatively easy to use, such systems detect only a fraction of adverse events, are underused by physicians, and yield data that often are not analyzed or disseminated promptly. This analysis of data from a commercial, web-based system at an academic hospital confirms some prior concerns, but the authors were able to demonstrate that rapid review of reports resulted in specific system changes to improve workflow and safety. A prior article presented a framework for using incident reporting data to improve patient safety.
Journal Article > Commentary
Selection of indicators for continuous monitoring of patient safety: recommendations of the project 'safety improvement for patients in Europe.'
Kristensen S, Mainz J, Bartels P. Int J Qual Health Care. 2009;21:169-175.
This article describes the development of an evidence-based methodology to assess patient safety improvement work in Europe.
Journal Article > Review
Dückers M, Faber M, Cruijsberg J, Grol R, Schoonhoven L, Wensing M. Med Care Res Rev. 2009;66(suppl 6):90S-119S.
Improving patient safety requires development of a culture of safety and transformation into a learning organization—one that has the capacity to rapidly address problems through information sharing and learning from past experience. In this systematic review, the authors characterize the published literature on organizational safety programs, and summarize published data on error detection methods (such as incident reporting systems), error analysis, and systems to mitigate and reduce specific errors (such as diagnostic errors and medication errors). The review is limited by publication bias (the preferential publication of studies with positive results) and the descriptive nature of most studies, reducing the generalizability of these studies for other organizations. An AHRQ WebM&M perspective discusses organizational approaches to safety improvement in academic and community settings.
Journal Article > Review
Cao LY, Taylor JS, Vidimos A. Dermatol Online J. 2010;16:3.
This review examines numerous safety issues relevant to outpatient dermatology practice, including medication errors, diagnostic errors, office-based surgery, wrong-site procedures, and laser safety.