Narrow Results Clear All
- Communication Improvement 2
- Culture of Safety 2
- Education and Training 2
- Error Reporting and Analysis 6
- Human Factors Engineering 1
- Legal and Policy Approaches 1
- Quality Improvement Strategies
- Specialization of Care 1
- Technologic Approaches 1
- Device-related Complications 2
- Identification Errors 2
- Medical Complications 8
- Medication Safety 1
- Psychological and Social Complications 1
- Surgical Complications 4
Search results for ""
Cases & Commentaries
- Web M&M
Darren R. Linkin, MD; Ebbing Lautenbach, MD, MPH, MSCE; February 2004
Infection Control notices an uptick in post-operative wound infections for patients from one OR team. Environmental rounds reveal "sloppy" practices.
Cases & Commentaries
- Web M&M
Ross Koppel, PhD; April 2009
A patient hospitalized with Pneumocystis jiroveci pneumonia and advanced AIDS is given another patient's malignant biopsy results, leading his primary physician to mistakenly recommend hospice care.
Perspectives on Safety > Interview
Prevention of Urinary Tract Infections: Lessons for Patient Safety, November 2008
Sanjay Saint, MD, MPH, is Professor of Medicine at the University of Michigan and the Ann Arbor VA Medical Center in Ann Arbor, Michigan. Dr. Saint's research has focused on reducing health care–associated infections, with a particular focus on preventing catheter-related urinary tract infections (UTIs). We asked him to speak with us about how research on UTI prevention provides broader lessons for patient safety.
ASQ Quarterly Quality Report. Milwaukee, WI: American Society of Quality; October 2008.
This report describes strategies for health care institutions to prevent never events, based on results of a 2008 survey of quality professionals.
Web Resource > Multi-use Website
Ohio Business Roundtable. 41 S. High Street, Suite 2240, Columbus, OH, 43215.
Journal Article > Study
Eber MR, Laxminarayan R, Perencevich EN, Malani A. Arch Intern Med. 2010;170:347-353.
Health care–associated infections are common and the subject of wide-scale prevention programs, despite concerns about their use as a quality metric. This study used a national database to examine the clinical and economic costs attributed to the development of health care–associated sepsis and pneumonia. Analyzing nearly 600,000 cases, investigators found 2.3 million hospitalization days, $8.1 billion in in-hospital costs, and 48,000 preventable deaths attributed to health care–associated sepsis and pneumonia. They also reported at least 40% higher length of stay and costs in patients with these complications who underwent invasive procedures compared to those who did not. Despite limitations in utilizing administrative data to draw clinical details, the findings are notable. A related commentary [see link below] discusses reducing preventable harm in the context of this study's findings, calling for greater investments in the science of health care quality and safety.
Lucado J, Paez K, Andrews R, Steiner C. HCUP Statistical Brief #94. Rockville, MD: Agency for Healthcare Research and Quality; August 2010.
Harrisburg, PA: Patient Safety Authority; May 2019.
This report summarizes patient safety improvement work in the state of Pennsylvania and reviews the 2018 activities of the Patient Safety Authority, including the launch of the Center of Excellence for Improving Diagnosis, outreach programs, liaison efforts, and the convening of the first patient safety conference for the state.
Allegranzi B, Nejad SB, Castillejos GG, Kilpatrick C, Kelley E, Mathai E; Clean Care is Safer Care Team. Geneva, Switzerland: World Health Organization; 2011. ISBN: 9789241501507.
This report reviewed the literature on health care–associated infections and found it to be the most prevalent adverse event affecting patients worldwide.