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Journal Article > Study
Lasiter S, Duffy J. J Nurs Adm. 2013;43:30-66.
This qualitative study explores the processes by which nurses create a safe environment for hospitalized elderly patients.
Web Resource > Multi-use Website
Society of Hospital Medicine.
This Web site provides resources for a national initiative to improve the safety and quality of patient transitions from hospital to home. The program is accepting rolling applications for hospitals that want to participate and receive assistance implementing the tools specific to their environment.
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; November 2010. Report No. OEI-06-09-00090.
Hospitalized patients continue to suffer iatrogenic harm, according to this study of Medicare patients completed by the Office of the Inspector General (OIG). Using methodology similar to the landmark Harvard Medical Practice Study, this study found that 13.5% of hospitalized Medicare patients experienced an adverse event, of which nearly half were considered preventable. However, fewer than 2% of patients experienced either a never event or a preventable complication for which hospitals are no longer reimbursed by the Centers for Medicare and Medicaid Services. These results are similar to the OIG's prior 2008 report. Based on these results, OIG recommends further efforts to accurately measure adverse events, and also recommends broadening the "no pay for errors" policy. The challenges of accurately measuring safety problems are discussed in an AHRQ WebM&M commentary.