Narrow Results Clear All
- Communication Improvement 5
- Culture of Safety 2
- Education and Training 1
- Error Reporting and Analysis 3
- Legal and Policy Approaches 3
- Quality Improvement Strategies
- Teamwork 1
- Diagnostic Errors 1
- Discontinuities, Gaps, and Hand-Off Problems 1
- Identification Errors 5
- Medical Complications 4
- Medication Safety 3
- Nonsurgical Procedural Complications 1
- Surgical Complications
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National Priorities Partnership. Washington, DC: National Quality Forum; 2008. ISBN: 1933875194.
This report resulted from a consensus program involving 28 national organizations that sought to outline goals for improving the US health care system and share examples of such efforts in patient safety and other identified areas.
Journal Article > Study
Weingart SN, Morway L, Brouillard D, et al. Jt Comm J Qual Patient Saf. 2009;35:206-215.
Patients are increasingly being encouraged to be proactive in ensuring their own safety, and many organizations recommend specific actions that patients should take, such as maintaining a current list of medications or asking providers to wash their hands. However, prior research has shown that many patients are not comfortable assuming an active role in their own safety. This study reveals another problem with encouraging patient involvement—the lack of a standardized set of recommendations. The investigators reviewed recommendations from 26 organizations and found wide variation in the types and utility of suggested patient actions. Development of a unified set of recommendations for patients would likely help providers and patients work together to improve safety.
Seeking a safer surgery: some states crack down on doctors who perform unregulated outpatient procedures.
Landro L. Wall Street Journal. July 21, 2009:D1.
This article discusses growing legal oversight on outpatient surgery performed in physicians' offices and identifies ways in which patients can assess a facility before deciding to have a procedure there.
Cohen E. Empowered Patient. CNN.com. November 13, 2009.
This news story describes an incident of patient misidentification and offers tips to help patients confirm their care during a hospitalization.
Altman LK. New York Times. December 11, 2001;1:1.
This news piece reports on wrong-site and wrong-patient surgery and describes efforts to prevent surgical errors following a Joint Commission sentinel event alert on the topic.
Clarke S, Savard M. Good Morning America. ABC News. March 22, 2010.
This television interview offers recommendations for patients to keep themselves safe while in the hospital. Sample tips are to obtain copies of important records and carefully consider timing when scheduling procedures.
National Quality Forum. Washington, DC: National Quality Forum; 2010.
The National Quality Forum originally published the Safe Practices for Better Healthcare in 2003. These practices are intended to be universally applicable, "gold standard" interventions for reducing preventable harm, and have been widely endorsed and implemented. As in the 2009 update, the 34 specific practices are organized into seven content areas: creating a culture of safety, providing patient-centered care and disclosing errors, matching health care needs with delivery capacity, facilitating information transfer and clear communication between providers, managing medications safely, preventing health care–associated infections, and implementing safe practices for specific clinical conditions and sites of care. There are no major changes in the recommended practices since 2009, but the report contains specific recommendations on engaging patients and families in safety efforts.
Journal Article > Commentary
Bloomington, MN: Institute for Clinical Systems Improvement; 2010.
This protocol is designed to protect against wrong-site incidents in ambulatory care and to improve team communication and patient engagement.
Journal Article > Study
Patient participation in surgical site marking: can this be an additional tool to help avoid wrong-site surgery?
Bergal LM, Schwarzkopf R, Walsh M, Tejwani NC. J Patient Saf. 2010;6:221-225.
Wrong-site surgeries remain a persistent safety issue, despite extensive efforts by regulatory bodies and professional societies to address the problem. One such intervention, initially adopted by the American Academy of Orthopaedic Surgeons, requires surgeons to sign the site of the surgery by marking the site of the operation on the body. This initiative has been less successful than hoped. In this study, investigators attempted to engage patients in safety by having patients themselves sign the site. Unfortunately, fewer than 70% of patients successfully followed the instructions and successfully marked the incision site. While only a few patients committed an overt error (i.e., signing the wrong site), the suboptimal adherence in this study indicates that site marking protocols may not benefit from increased patient engagement.