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Perspectives on Safety > Interview
Surgical Errors, September 2007
Atul Gawande, MD, MA, MPH, Associate Professor of Surgery at Harvard Medical School and the Harvard School of Public Health, is an accomplished surgeon and writer and is the recipient of a 2006 MacArthur Fellowship. He is an active clinician at Brigham and Women's Hospital and the Dana Farber Cancer Institute. Dr. Gawande has written two acclaimed and best-selling books: Complications: A Surgeon's Notes on an Imperfect Science and Better: A Surgeon's Notes on Performance. A staff writer for the New Yorker, he also recently completed a stint as a guest columnist for the New York Times. Dr. Gawande is leading the World Health Organization's Second Global Patient Safety Challenge: "Safe Surgery Saves Lives." We asked him to speak with us about professionalism, training, patient safety, and the writing process.
Oakbrook Terrace, IL: The Joint Commission; March 2007.
This report reveals that the overall quality of care delivered by US hospitals improved steadily between 2003 and 2005, as measured by adherence to evidence-based treatments for myocardial infarction, congestive heart failure, and pneumonia. Adherence to the Joint Commission's National Patient Safety Goals, which include measures to prevent wrong-site surgery and promote medication reconciliation, was also measured. Although results on these measures showed a more mixed picture, the report cautions that changes in measurement during the study period limit interpretability of the results.
Journal Article > Study
Publicly available hospital comparison web sites: determination of useful, valid, and appropriate information for comparing surgical quality.
Leonardi MJ, McGory ML, Ko CY. Arch Surg. 2007;142:863-869.
The growing focus on health care quality has led to the development of several Web sites that make hospital quality information publicly available to consumers. This study evaluated six such Web sites (the Centers for Medicaid and Medicare Services' Hospital Compare, the Joint Commission's Quality Check, the Leapfrog Group, and three commercial sites) for ease of use, data accuracy, and consistency of hospital rankings for several surgical quality measures. In general, the governmental and non-profit Web sites were rated as easier to use and had more complete information. However, the authors found significant variation in the risk adjustment methods used and the types of outcomes reported on each Web site, leading to poor reproducibility of rankings for specific surgical procedures.
Smith S. Boston Globe. July 30, 2008;Metro section:1A.
This article reports on the incidence of wrong site surgeries in Massachusetts and describes complex factors that may contribute to such errors occurring in spinal surgery.
Journal Article > Study
Validity of selected AHRQ Patient Safety Indicators based on VA National Surgical Quality Improvement program data.
Romano PS, Mull HJ, Rivard PE, et al. Health Serv Res. 2009;44:182-204.
The AHRQ Patient Safety Indicators (PSIs) were originally developed as a means of screening administrative data to identify potential patient safety problems. However, they are increasingly being used for quality measurement and hospital comparison purposes. This study sought to evaluate the accuracy of surgical PSIs for identification of true safety issues, by comparing PSI-detected events to clinical data. The PSIs tested had only moderate sensitivity and specificity for detecting clinical adverse events, lending support to prior research, which concluded that PSIs should be used only for screening purposes. An AHRQ WebM&M commentary discusses the limitations of using PSIs for public reporting and hospital comparison purposes.
Journal Article > Commentary
Cassidy J. BMJ. 2009;339:b2693.
This article examines the impact of whistleblowing on the caregivers involved, using the Bristol incident and other high-profile examples from the United Kingdom.
Oakbrook Terrace, IL: The Joint Commission; January 2010.
America's hospitals continued to improve the quality of care they provide for myocardial infarction, congestive heart failure, pneumonia, and surgical care, according to the newest report from The Joint Commission. Compared to the prior report published in 2007, hospitals increased their provision of evidence-based treatments across all four disease processes. In particular, significant improvements were achieved in use of measures to prevent surgical site infections. While the prior report provided data on adherence to the National Patient Safety Goals, these measures were not discussed in the current report.
Journal Article > Study
Adherence to Surgical Care Improvement Project measures and the association with postoperative infections.
Stulberg JJ, Delaney CP, Neuhauser DV, Aron DC, Fu P, Koroukian SM. JAMA. 2010;303:2479-2485.
Public reporting of quality measures is now widely used as a means of spurring hospitals to invest in patient safety and quality improvement efforts; however, it remains unclear if reported measures truly indicate a higher quality of care. In this study of more than 400,000 patients, researchers analyzed the relationship between adherence to recommended measures to prevent postoperative surgical infections and the subsequent development of such infections. They found that infection rates decreased only when all recommended interventions were carried out; performance of individual interventions did not seem to affect infection rates. Checklists—a relatively simple tool to ensure that all recommended steps of a process are carried out for every patient—initially gained fame as a means of preventing central line infections, and have subsequently been demonstrated to reduce surgical site infections.
O'Reilly KB. American Medical News. August 15, 2011.
This news article reports on health care providers who have publicly revealed direct involvement in cases of medical errors, with a goal of encouraging open disclosure, encouraging safety checks, and improving patient safety.
Gabler E. New York Times. May 31, 2019.
Pediatric cardiac surgery is highly technical and risky. This newspaper article reports on a poorly performing pediatric cardiac surgery program, concerns raised by staff, and insufficient response from organizational leadership. Lack of data transparency, insufficient resources, and limited program capabilities to support a complex program contributed to poor outcomes for pediatric patients.