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Journal Article > Study
Risk reduction for adverse drug events through sequential implementation of patient safety initiatives in a children's hospital.
Leonard MS, Cimino M, Shaha S, McDougal S, Pilliod J, Brodsky L. Pediatrics. 2006;118:e1124-e1129.
This study describes an effort to reduce adverse drug events (ADEs) at a pediatric tertiary care hospital through interventions targeting the clinical staff. These interventions included use of a Web-based tutorial on medication safety, a "zero-tolerance" policy whereby any medication errors would have to be rewritten, and feedback of individual data on prescribing error to clinicians. The intervention achieved impressive reductions in potential ADEs, defined as any incompletely written medication order, but did not document the incidence of ADEs resulting in patient harm. The baseline incidence of potential ADEs was also higher than that seen in prior research.
Legislation/Regulation > Multi-use Website
World Health Organization.
This Web site shares information on a variety of initiatives from the World Alliance for Patient Safety.
Tools/Toolkit > Multi-use Website
Association of periOperative Registered Nurses.
This Web site includes information and resources for National Time Out Day, an initiative to raise awareness on the importance of surgical team time outs. The 2019 observation is June 12th.
Journal Article > Study
Publicly available hospital comparison web sites: determination of useful, valid, and appropriate information for comparing surgical quality.
Leonardi MJ, McGory ML, Ko CY. Arch Surg. 2007;142:863-869.
The growing focus on health care quality has led to the development of several Web sites that make hospital quality information publicly available to consumers. This study evaluated six such Web sites (the Centers for Medicaid and Medicare Services' Hospital Compare, the Joint Commission's Quality Check, the Leapfrog Group, and three commercial sites) for ease of use, data accuracy, and consistency of hospital rankings for several surgical quality measures. In general, the governmental and non-profit Web sites were rated as easier to use and had more complete information. However, the authors found significant variation in the risk adjustment methods used and the types of outcomes reported on each Web site, leading to poor reproducibility of rankings for specific surgical procedures.