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- Patient Safety Primers 1
- WebM&M Cases 1
- Perspectives on Safety 3
- Review 1
- Study 31
- Slideset 1
- Book/Report 25
- Legislation/Regulation 2
- Newspaper/Magazine Article 132
- Newsletter/Journal 1
- Special or Theme Issue 4
- Toolkit 3
- Web Resource 33
- Meeting/Conference 2
- Press Release/Announcement 3
- Communication Improvement 45
- Culture of Safety 6
- Education and Training 42
Error Reporting and Analysis
- Error Reporting 57
- Human Factors Engineering 19
- Legal and Policy Approaches 69
- Logistical Approaches 11
- Policies and Operations 1
- Quality Improvement Strategies 31
- Research Directions 4
- Specialization of Care 3
- Teamwork 1
- Technologic Approaches 27
- Transparency and Accountability 3
- Alert fatigue 2
- Device-related Complications 6
- Diagnostic Errors 24
- Discontinuities, Gaps, and Hand-Off Problems 11
- Drug shortages 3
- Failure to rescue 1
- Fatigue and Sleep Deprivation 5
- Identification Errors 7
- Delirium 1
- Medication Errors/Preventable Adverse Drug Events 28
- Nonsurgical Procedural Complications 3
- Overtreatment 4
- Psychological and Social Complications 20
- Surgical Complications 27
- Transfusion Complications 2
- Ambulatory Care 38
- General Hospitals 29
- Long-Term Care 6
- Outpatient Surgery 5
- Psychiatric Facilities 3
- Internal Medicine 57
- Nursing 6
- Palliative Care 1
- Pharmacy 17
- Family Members and Caregivers 22
- Health Care Executives and Administrators 64
Health Care Providers
- Nurses 7
- Physicians 21
Non-Health Care Professionals
- Media 3
- Australia and New Zealand 5
- Europe 21
- Canada 9
United States of America
United States Federal Government
- Department of Health and Human Services (HHS) 11
- United States Federal Government 15
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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.
Perspectives on Safety > Perspective
with commentary by Ronen Rozenblum, MD, MPH, and David Bates, MD, MS, Patient-facing Technologies: Opportunities and Challenges for Patient Safety, November 2017
This piece explores how patient-facing technologies can enable patients to be more responsible for their care and improve the way clinicians practice.
Perspectives on Safety > Interview
Patient-facing Technologies: Opportunities and Challenges for Patient Safety, November 2017
Wanda Pratt is a professor in the Information School and an adjunct in Biomedical and Health Informatics in the School of Medicine at the University of Washington. We spoke with her about patient-facing technologies, including the opportunities and challenges for patient safety.
Perspectives on Safety > Annual Perspective
with commentary by Rachel J. Stern, MD, and Urmimala Sarkar, MD, 2017
Patient engagement in safety has evolved from obscurity to maturity over the past two decades. This Annual Perspective highlights emerging approaches to engaging patients and caregivers in safety efforts, including novel technological innovations, and summarizes the existing evidence on the efficacy of such approaches.
Patient Safety Primers
Anyone can find it challenging to understand medical terms, and millions of Americans have trouble understanding and acting upon health information. The mismatch between individuals' health literacy skills and the complexity of health information and health care tasks involved in managing health has implications on patient safety.
Zipperer LA, Cushman S, eds. Chicago, IL: National Patient Safety Foundation; 2001. ISBN: 1579471889.
The editors present eight chapters covering key areas of patient safety: epidemiology of error, reporting of error, lessons from anesthesiology, emotional response to error, human factors, medication error, and general studies of error and administrative issues.
Dyer C. BMJ. 2005;330:1228.
This article reports on the National Health Service's plan to handle small claims from medical mistakes without litigation.
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.
Journal Article > Study
Agoritsas T, Bovier PA, Perneger TV. J Gen Intern Med. 2005;20:922-928.
The authors surveyed adults recently discharged from a Swiss hospital and found that patients can effectively pinpoint in-hospital adverse events.
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.
Journal Article > Government Resource
Centers for Disease Control and Prevention. MMWR Morb Mortal Wkly Rep. January 13, 2006;55:1-5.
This study reports on the incidence of unintentional exposure to prescription and over-the-counter medications that are not properly stored out of reach of young children.
Journal Article > Study
Sharif I, Lo S, Ozuah PO. J Health Care Poor Underserved. 2006;17:65-69.
The authors surveyed pharmacies in the Bronx, New York, and found that 69% could provide prescription labels in Spanish, and that most used a computer program to translate the labels.
Journal Article > Study
Patient assessments of a hypothetical medical error: effects of health outcome, disclosure, and staff responsiveness.
Cleopas A, Villaveces A, Charvet A, Bovier PA, Kolly V, Perneger TV. Qual Saf Health Care. 2006;15:136-141.
This study presented a medication error scenario to a group of recently discharged patients and discovered that patients viewed the error less favorably in association with a slow hospital response, a lack of disclosure, and the presence of serious health effects. Using a mailed questionnaire, investigators achieved a 70% response rate from eligible patients, providing more than 1200 evaluations of the scenario. The three primary findings noted above appeared additive and, in particular, the finding that slow and ineffective handling of the error by health care staff produced a more negative response independent of disclosure. A past study similarly discussed patient and physician attitudes regarding the disclosure of medical errors.
Landro L. Wall Street Journal (Eastern edition). May 23, 2006:D1. [reprinted on Post-Gazette.com]
This article discusses the shared responsibility among patients, hospitals, and practitioners to support appropriate drug administration through medication reconciliation.
National Patient Safety Agency. London, UK: National Health Service.
These documents summarize National Patient Safety Agency incident reporting data from the first year of data collection. They are accompanied by workbooks for data review, slide sets and trends analysis.
Journal Article > Study
Coleman EA, Parry C, Chalmers S, Min SJ. Arch Intern Med. 2006;166:1822-1828.
Prior studies have documented the safety problems that befall patients with complex illnesses at the time of transition from one setting of care to another. In this trial conducted in an integrated delivery system, patients were randomized to receive usual care or the care transitions intervention at the time of hospital discharge. Intervention patients received a personal health record and a "transition coach," who assisted with continuity of care across settings, arranged home visits after discharge, and helped train patients and caregivers in self-care methods. The foci of the intervention were on ensuring accurate medication usage and appropriate follow-up care. The intervention successfully reduced the likelihood of hospital readmission for 3 months after discharge and appeared to be cost effective.
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.
Harrisburg, PA: Pennsylvania Health Care Cost Containment Council; November 2006.
This report includes findings on the number and rate of infections in Pennsylvania hospitals in 2005.
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.