Narrow Results Clear All
- WebM&M Cases 1
- Commentary 27
- Review 14
- Study 61
- Slideset 1
- Book/Report 50
- Legislation/Regulation 5
- Newspaper/Magazine Article 18
- Special or Theme Issue 3
- Tools/Toolkit 1
- Web Resource 32
- Award 4
- Meeting/Conference 1
- Press Release/Announcement 2
- Communication Improvement 12
- Culture of Safety 18
Education and Training
- Students 1
Error Reporting and Analysis
- Never Events 12
- Error Reporting 41
- Human Factors Engineering 3
Legal and Policy Approaches
- Regulation 21
- Logistical Approaches 22
- Quality Improvement Strategies 51
- Research Directions 1
- Specialization of Care 4
- Teamwork 3
- Clinical Information Systems 11
- Transparency and Accountability 1
- Device-related Complications 9
- Diagnostic Errors 3
- Discontinuities, Gaps, and Hand-Off Problems 6
- Drug shortages 3
- Fatigue and Sleep Deprivation 18
- Identification Errors 2
- Medical Complications 48
- Medication Safety 14
- Nonsurgical Procedural Complications 1
- Psychological and Social Complications 1
- Surgical Complications 19
- Transfusion Complications 1
- Internal Medicine 154
- Surgery 5
- Nursing 1
- Pharmacy 3
- Health Care Executives and Administrators 172
Health Care Providers
- Nurses 1
- Physicians 12
Non-Health Care Professionals
- Media 5
- Patients 24
- Africa 1
- Australia and New Zealand 2
- Europe 31
- Canada 4
Search results for ""
Cases & Commentaries
- Spotlight Case
- Web M&M
James E. Sabin, MD; December 2009
A man with a history of IV drug use is admitted to the hospital and found to have an epidural abscess with surrounding osteomyelitis. Although the treatment plan required weeks of IV antibiotics, the patient (who fought with the nursing staff and threatened to leave against medical advice [AMA]) was discharged after 2 weeks on oral antibiotics. His condition worsened, and he returned 3 weeks later, but he ultimately left AMA and was lost to follow-up.
Journal Article > Commentary
Medication errors in family practice, in hospitals and after discharge from the hospital: an ethical analysis.
Clark PA. J Law Med Ethics. 2004;32:349-357.
In this article, the author urges the medical community to universally apply the systems approach to safety toward the reduction of medical errors. The author calls for health care to take medication errors more seriously and for patients to help drive improvement.
Zimmerman R. Wall Street Journal. February 6, 2007:A1.
This article reports on a mother's campaign to educate parents about kernicterus and to make bilirubin tests standard for all newborns.
Journal Article > Review
Neale G, Vincent C, Darzi SA. J R Soc Promot Health. 2007;127:87-94.
The authors discuss the history of quality and safety initiatives in the United Kingdom and offer suggestions on how to improve physician involvement in these initiatives.
Legislation/Regulation > Pennsylvania Legislation
General Assembly of Pennsylvania. SB968 (2007).
This bill requires that Pennsylvania hospitals and nursing homes implement an internal infection control plan and report hospital-acquired infections.
Pear R. New York Times. August 19, 2007.
This article reports on a new Centers for Medicare and Medicaid Services (CMS) rule mandating that Medicare will no longer pay for treating certain preventable errors starting in 2008, including some hospital-acquired infections, decubitus ulcers, and retained foreign bodies. The policy is generating considerable discussion in patient safety circles, with some expressing concerns regarding the economic impact on hospitals and the increased efforts it is likely to create for hospitals to document certain patient problems present at the time of admission.
Lerner M. Star Tribune. September 18, 2007;News section:5B.
This article reports on Minnesota's adoption of a policy for hospitals to not charge patients or insurers for never events or consequent treatment.
Kowalczyk L. Boston Globe. September 17, 2007;Metro section:1A.
This article reports on how numerous Massachusetts hospitals have implemented policies to waive charges for the set of serious errors categorized as never events.
Journal Article > Commentary
Wachter RM, Foster NE, Dudley RA. Jt Comm J Qual Patient Saf. 2008;34:116-123.
Beginning in fiscal year 2009, Medicare will begin withholding payment for serious preventable adverse events. The announcement of this initiative has prompted significant debate in the safety community, with a past economic analysis suggesting that adverse events account for a small but significant proportion of overall Medicare hospital spending. This commentary outlines the details of the proposed policy, the estimated impact on costs, and the expected challenges in implementation. The latter include the capacity of health care systems to adequately measure when these events occur, whether evidence-based practices exist to prevent them, and how to ensure that such events were not ''present on admission''—a new coding category to identify patients whose events occurred prior to hospitalization. While the authors raise caution about monitoring its effects, they applaud the efforts of this landmark policy and remain hopeful that it will ultimately drive necessary system improvements.
Fuhrmans V. Wall Street Journal. January 15, 2008:D1.
This article reports on health insurance companies adopting the tactic of not paying for preventable errors, which parallels a similar federal decision.
Saving Lives, Saving Money: The Imperative for Computerized Physician Order Entry in Massachusetts Hospitals.
Adams M, Bates D, Coffman G, Everett W. Westborough, MA: Massachusetts Technology Collaborative and New England Healthcare Institute; 2008.
Analyzing patient charts at six community hospitals in Massachusetts, this report reveals to what extent adopting computerized physician order entry could affect clinical outcomes and impart financial savings.
Health-Care-Associated Infections in Hospitals: Leadership Needed from HHS to Prioritize Prevention Practices and Improve Data on these Infections.
Washington, DC: United States Government Accountability Office; March 31, 2008. Publication GAO-08-283.
This report examines US government standards, procedures, and data collection methods related to health-care-associated infections (HAI) and recommends increased integration across program databases.
O'Reilly KB. American Medical News. May 12, 2008.
This article reports that the Centers for Medicare and Medicaid Services (CMS) has proposed expanding the list of hospital-acquired conditions that it will no longer cover.
NY Medicaid ups the ante: by refusing to pay for 14 'never events,' the nation's biggest Medicaid program could propel other states into action.
DerGurahian J. Mod Healthc. June 16, 2008;38:6.
Legislation/Regulation > Organizational Policy/Guidelines
Chicago, IL: American Hospital Association; February 12, 2008.
This quality advisory details principles adopted by the American Hospital Association Board of Trustees to guide the development of hospital no-charge policies.
Journal Article > Study
Encinosa WE, Hellinger FJ. Health Serv Res. 2008;43:2067-2085.
The financial costs associated with medical errors have gained increasing attention, due to the Centers for Medicare and Medicaid Services policy of nonpayment for certain preventable adverse events. This study sought to estimate costs associated with adverse events (measured by the Agency for Healthcare Research and Quality's Patient Safety Indicators) in surgical patients. Importantly, by measuring costs for a 90-day period after surgery, the authors were able to estimate the postdischarge financial impact of adverse events. Up to 20% of costs were incurred after hospital discharge, and the investigators found significant impact of adverse events on mortality and hospital readmissions. The implications of this study and prior research in this area help formulate a business case for safety.
Journal Article > Study
Analysis of 23,364 patient-generated, physician-reviewed malpractice claims from a non-tort, blame-free, national patient insurance system: lessons learned from Sweden.
Pukk-Härenstam K, Ask J, Brommels M, Thor J, Penaloza RV, Gaffney FA. Qual Saf Health Care. 2008;17:259-263.
Malpractice claims in Sweden are compensated if an independent physician review confirms that harm resulted from physician error. Over the 8-year period covered in this study, compensation was provided in almost half of cases.
Journal Article > Study
Steering patients to safer hospitals? The effect of a tiered hospital network on hospital admissions.
Scanlon DP, Lindrooth RC, Christianson JB. Health Serv Res. 2008;43:1849-1868.
This study discovered that providing unionized employees with a financial incentive to choose safer hospitals (defined by Leapfrog criteria) influenced decision-making compared to their nonunionized counterparts without such incentives.
Journal Article > Commentary
Volpp KG, Landrigan CP. JAMA. 2008;300:1197-1199.
The Accreditation Council for Graduate Medical Education's 2003 regulations limiting housestaff duty hours have generated an expansive field of research into their impact on fatigue, workload, clinical outcomes, and patient safety. This commentary aims to put the current research into a practical context and provides eight priorities that should guide teaching institutions in their efforts to balance both physician and patient safety. The authors highlight alternative staffing models (e.g., no more 24-hour shifts), improved sign-out procedures, greater monitoring and evaluation of duty hour changes, the importance of adequate supervision and workload intensity, and better designed financial incentives to promote successful policy change. The Agency for Healthcare Research and Quality (AHRQ) has sponsored an Institute of Medicine (IOM) committee to review the important research and related issues around work hour restrictions.
Health-Care-Associated Infections in Hospitals: An Overview of State Reporting Programs and Individual Hospital Initiatives to Reduce Certain Infections.
Washington, DC: United States Government Accountability Office; September 2008. Publication GAO-08-808.
This report describes state reporting programs for health care–associated infection (HAI), hospital initiatives to reduce MRSA (methicillin-resistant Staphylococcus aureus), and challenges encountered in HAI reduction.