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Communication between Providers
- Sbar 1
- Communication between Providers 6
- Culture of Safety 2
- Education and Training 7
- Error Reporting and Analysis 2
- Human Factors Engineering
- Legal and Policy Approaches 6
- Logistical Approaches 1
- Policies and Operations 1
- Quality Improvement Strategies 8
- Specialization of Care 1
- Teamwork 3
- Technologic Approaches 1
- Device-related Complications 2
- Diagnostic Errors 1
- Discontinuities, Gaps, and Hand-Off Problems 2
- Identification Errors 4
- Medical Complications 4
- Medication Safety 5
- Nonsurgical Procedural Complications 1
- Surgical Complications 14
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Tools/Toolkit > Fact Sheet/FAQs
Rockville, MD: Agency for Healthcare Research and Quality; September 2010. AHRQ Publication No. 10-M052-C.
This 5-point checklist provides consumers with steps to help ensure the safety of their medication use.
Rockville, MD: Agency for Healthcare Research and Quality; December 2005.
This consumer video provides content complementary to the Agency for Healthcare Research and Quality checklist Check Your Medicines: Tips for Taking Medicines Safely.
Tools/Toolkit > Fact Sheet/FAQs
Vienna, VA: The Partnership for Safe Medicines; 2005.
This checklist will help patients determine if medications are possibly counterfeit, and it explains how to report problems.
Bernhard B. The Orange County Register. April 19, 2006.
This article reports on an Anaheim anesthesiologist's pre-surgery checklist, inspired by similar checklists used in the aviation industry.
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.
P-I Staff and News Services. Seattle Post-Intelligencer. June 15, 2006:A1.
This article article reports on the results of the the 100,000 Lives Campaign.
Landro L. Wall Street Journal (Eastern edition). June 28, 2006:D1. [reprinted on Post-gazette.com].
This article reports on communication interventions such as SBAR (Situation-Background-Assessment-Recommendation) that make patient hand-offs more reliable.
Journal Article > Commentary
The author explains the Joint Commission on Accreditation of Healthcare Organizations' Universal Protocol on surgical site verification in the context of its implementation in a New Jersey hospital.
Abelson R. New York Times. May 17, 2007;Business section:1.
This article reports on a Pennsylvania hospital system that offers a flat fee for bypass surgery and a guarantee for follow-up care should complications arise.
Rockville, MD: Agency for Healthcare Research and Quality. June 20, 2007.
This podcast discusses the importance of handwashing to reduce infections in hospitals as well as how consumers can help improve clinician compliance.
Associated Press. MSNBC. November 27, 2007.
This news article reports repeated incidents of wrong-side surgery at the same facility, and state and hospital reactions to the errors.
Gawande A. The New Yorker. December 10, 2007;83:86-95.
This article by bestselling author and surgeon Atul Gawande illustrates the complexity of intensive care and profiles Peter Pronovost, the Johns Hopkins intensivist and safety leader whose efforts to standardize safety practices led to remarkable reductions in ICU harm in Michigan hospitals. It goes on to a broader discussion of how checklists and decision support have reduced errors and transformed safety in critical care. Gawande also reflects on how implementation of standardized approaches often conflicts with the traditional physician culture, which prizes individual expertise over all else.
Carbonara P. Fast Company. October 2008.
This magazine article describes how one health system is using an evidence-based, pay-for-performance program to reduce errors and improve outcomes in coronary-artery bypass graft (CABG) surgery.
Gawande A. New York, NY: Metropolitan Books; 2009. ISBN: 9780805091748.
Harvard surgeon Atul Gawande has emerged as this generation's preeminent physician–author, through his articles in The New Yorker on topics ranging from quality improvement to the costs of health care, and his books, Complications and Better. In his new book, The Checklist Manifesto: How to Get Things Right, Dr. Gawande elegantly describes the history of the checklist as a quality and safety tool, in fields ranging from flying airplanes to building skyscrapers. In health care, he focuses on the Michigan Keystone Project, in which the use of checklists led to a remarkable decrease in the rate of central line–associated bloodstream infections, and on his own work with the World Health Organization's Safe Surgery Saves Lives program, where checklist use was associated with a striking decrease in surgical complications. An AHRQ WebM&M interview with Dr. Gawande discusses professionalism, surgical errors, and patient safety. A Patient Safety Primer on checklists is also featured on AHRQ PSNet.
Consumer Reports. March 2010;75:16-21.
Bowser BA. PBS News Hour. February 8, 2010.
Stein L. St. Petersburg Times. June 21, 2010.
Reporting on wrong-site surgeries in Florida hospitals, this newspaper article describes how timeouts have changed the nature and frequency of surgical errors.
Maminta J. News 8 WTNH. February 3, 2012.
This news video highlights one hospital's effort to improve teamwork and communication in surgery to prevent errors.
Dwyer J. New York Times. October 25, 2012.
Kane J. PBS NewsHour. October 23, 2012.
This video reveals how checklists can help patients and their families ensure safety during hospital care.