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- Culture of Safety 1
- Education and Training 1
- Error Reporting and Analysis 3
- Legal and Policy Approaches
- Quality Improvement Strategies 3
- Diagnostic Errors 1
- Discontinuities, Gaps, and Hand-Off Problems 1
- Identification Errors 1
- Medical Complications 1
- Medication Safety 2
- Surgical Complications 2
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World Health Organization.
This publication shares news related to the World Health Organization's Global Patient Safety Challenge.
Journal Article > Commentary
Dekker S. J Law Med Ethics. 2007;35:463-470.
The author analyzes one Swedish medication error incident that resulted in criminal charges against the nurse involved and discusses how the media contorted the assignment of blame for the failure.
Journal Article > Study
Rhodes P, Giles SJ, Cook GA, et al. Qual Saf Health Care. 2008;17:409-415.
Wrong-site surgery is a rare yet devastating outcome. Prevention strategies have focused on adoption of the Joint Commission's Universal Protocol and structured communication tools such as time outs. This study examined the impact of a national safety alert issued to all NHS hospital trusts in England and Wales about preventing wrong-site surgery. Investigators interviewed surgeons and senior nurses in the 12-15 months following the alert and discovered significant variation in the adoption of proposed recommendations. While the alert was associated with greater awareness and surgical marking of sites, the authors discuss the complex nature of change management around the new policy. A related commentary [see link below] discusses the broader context of efforts to eliminate wrong-site surgery. A past AHRQ WebM&M commentary discussed the factors contributing to a near-miss wrong-site surgery, and a recent commentary outlined the anatomy of a time out.
Journal Article > Commentary
Cassidy J. BMJ. 2009;339:b2693.
This article examines the impact of whistleblowing on the caregivers involved, using the Bristol incident and other high-profile examples from the United Kingdom.
Journal Article > Study
High-profile investigations into hospital safety problems in England did not prompt patients to switch providers.
Laverty AA, Smith PC, Pape UJ, Mears A, Wachter RM, Millett C. Health Aff (Millwood). 2012;31:593-601.
While medical errors continue to affect patients on a daily basis, most organizations fear high-profile cases that land on front pages of newspapers or lead to extensive regulatory intervention. This study evaluated the role of England's Care Quality Commission in their own regulatory investigation of major issues occurring in three hospitals. The investigations led to considerable media attention, but whether this influenced patient behavior was unknown. The authors found that the investigations had zero impact on utilization at two of the hospitals. The third experienced a decrease in inpatient admissions and new patient visits, but the effect dissipated 6 months following the public report. In an era of greater transparency and increased attention on patient safety, these findings suggest that patients' decision-making is perhaps less influenced than expected by such events. Two past AHRQ WebM&M perspectives discussed organizational change in the face of highly public errors at Duke and the Dana Farber Cancer Institute.
Harrow, Middlesex, UK: The Patients Association; 2013.
This publication provides patient and family accounts of incidents involving inadequate care or harm and highlights the need for improvements recommended in a National Health Services report.
Hughes J. BBC News. August 12, 2010.
This article reveals how the majority of hospitals have not acted on British National Health Services (NHS) safety alerts.
Patient Safety Investigation report into services at University Hospital Galway (UHG) and as reflected in the care provided to Savita Halappanavar.
Dublin, Ireland: Health Information and Quality Authority; October 2013.
This report presents results of an investigation into a hospital maternity service in Ireland, identifies numerous areas for improvement, and makes recommendations to enhance quality and safety.
Kremer W. BBC News Magazine. July 6, 2014.
This magazine article reports how weaknesses in physician understanding of statistics can lead to poorly informed discussions with patients about risks and treatment options. Using actual numbers instead of percentages may help prevent confusion.
Journal Article > Review
Systematic review on the prevalence, frequency and comparative value of adverse events data in social media.
Golder S, Norman G, Loke YK. Br J Clin Pharmacol. 2015;80:878-888.
Medication errors are common in the outpatient setting and frequently lead to emergency department visits and hospital admissions. The growth in social media use potentially provides a way to identify safety hazards quickly. This systematic review sought to examine whether social media could provide unique insights into safety issues compared to standard methods of detecting safety hazards. The included studies searched a variety of social media sites (e.g., Twitter, YouTube, and discussion forums) and found that a large number of adverse events are discussed in real time. Most of these events tended to be mild, such as symptoms or asymptomatic lab test abnormalities. Serious adverse events, those requiring urgent treatment or hospitalization, were relatively underrepresented. Although searching social media may help identify unique safety hazards, the investigators concluded that current evidence is insufficient to determine whether routine analysis of social media is of added benefit to traditional surveillance methods.