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Weber T, Ornstein C. Los Angeles Times. April 12, 2005.
This article reports on a death that occurred at the Martin Luther King Jr./Drew Medical Center after a patient's deteriorating vitals signs went unnoticed.
Hospital-error oversight called lax: state takes too long to investigate mistakes, patient advocates say.
Galloway A. Seattle Post-Intelligencer. May 5, 2005.
This article explores inefficiencies in the process for reporting and investigating adverse events in Washington and indicates that inconsistent error review is a problem across the nation.
Journal Article > Study
Stebbing C, Kaushal R, Bates DW. Pediatrics. 2006;117:1907-1914.
This study analyzed newspaper coverage of pediatric medication errors and adverse drug events in five countries to demonstrate increased interest in the topic over the past decade. Investigators examined the number of articles and the types of events covered and assessed the overall themes presented and framed by the media. The majority of articles published covered patient incidents followed by policy and then research in decreasing order of frequency. Despite the occasional occurrence of sensational reporting on errors, more than 70% of articles that were deemed to be negatively associated with patient safety were covered in a neutral manner.
Scobie S, Minghella E, Dale C, Thomson R, Lelliott P, Hill K. London, UK: National Patient Safety Agency; July 2006.
This report, the second in a series from the United Kingdom's National Patient Safety Agency, analyzes nearly 45,000 patient safety incidents relating to mental health that were reported to a nationwide incident reporting system. The majority of reported incidents were from inpatient mental health facilities, primarily involving patient accidents (including falls), disruptive or aggressive behavior, self-harming behavior, and missing (absconding) patients. The report summarizes existing initiatives to improve patient safety in mental health, makes specific recommendations for mental health providers, and identifies priority areas for future research.
Journal Article > Commentary
SQUIRE 2.0 (Standards for QUality Improvement Reporting Excellence): revised publication guidelines from a detailed consensus process.
Ogrinc G, Davies L, Goodman D, Batalden P, Davidoff F, Stevens D. BMJ Qual Saf. 2016;25:986-992.
The rapid growth in literature on patient safety and quality improvement (QI) has been accompanied by controversy about how such studies should be conducted and reported. Influential leaders have argued that QI studies demand a different standard of evaluation than traditional biomedical research, given their complexity. A contrary argument notes that failure to rigorously evaluate such research could result in wasted resources and unanticipated consequences if poorly evaluated interventions are widely implemented. Developed by expert consensus, these guidelines provide a blueprint for reporting the results of QI studies. Since its introduction in 2008, authors and journal editors have widely adopted these guidelines to standardize reporting of safety and QI studies. In 2015, the SQUIRE guidelines were revised through a process that included semistructured interviews, focus groups, consensus meetings, pilot testing with authors, and a public comment period. SQUIRE 2.0 improves the usability of the guidelines and omits the multiple sub-items that were felt to be too confusing for authors in the initial document.
Journal Article > Study
de Saint Maurice G, Auroy Y, Vincent C, Amalberti R. Qual Saf Health Care. 2010;19:327-331.
This study tracked adoption of a process-oriented safety rule and found that compliance eroded over time, with a major trigger being lack of compliance by a senior staff member. The authors provide caution about the role of policies to promote safety behaviors, particularly if such policies are not prioritized by staff as important.
Web Resource > Database/Directory
Columbia, SC: Mothers Against Medical Error; 2010.
This directory provides a listing of organizations and individuals dedicated to safe provision of health care.
Journal Article > Study
Interactive effects of nurse-experienced time pressure and burnout on patient safety: a cross-sectional survey.
Teng CI, Shyu YI, Chiou WK, Fan HC, Lam SM. Int J Nurs Stud. 2010;47:1442-1450.
The combination of burnout and time pressures appeared to be associated with patient safety risks, according to this survey of Taiwanese nurses.
Web Resource > Government Resource
Division of Licensing and Regulatory Services, Maine Department of Health and Human Services.
This Web site provides information about Maine's statewide incident reporting initiative and includes annual sentinel event reports.
Tallahassee, FL: Florida Hospital Association; August 2013.