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- Communication Improvement 1
- Culture of Safety 1
- Education and Training 1
- Error Reporting and Analysis 1
- Human Factors Engineering 2
- Legal and Policy Approaches
- Logistical Approaches 1
- Quality Improvement Strategies 3
- Technologic Approaches
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Cases & Commentaries
- Web M&M
Arpana Vidyarthi, MD; March 2004
Due to a series of incomplete signouts, information about a patient's post-operative leg pain and chest discomfort is not conveyed to the primary team. A PE is discovered post-mortem.
Perspectives on Safety > Interview
National Organizations in Safety, April 2014
Dr. Gandhi is President of the National Patient Safety Foundation and Associate Professor of Medicine at Harvard Medical School. We spoke with her about NPSF's evolving role in enhancing health care at a national level.
Journal Article > Study
Improving general practice computer systems for patient safety: qualitative study of key stakeholders.
Avery AJ, Savelyich BSP, Sheikh A, Morris CJ, Bowler I, Teasdale S. Qual Saf Health Care. 2007;16:28-33.
Enhanced information technology (IT) has been identified as a key component of improving patient safety, but development and implementation of health care IT systems have sometimes led to unintended consequences. In this study, the authors interviewed 31 health care IT stakeholders, ranging from IT developers to frontline clinicians, to identify priority areas for improving IT in the primary care setting. Interviewees voiced a strong interest in using IT for decision support but were frustrated with a perceived lack of attention to human factors engineering in current IT systems.
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; December 2008. Report No. OEI-06-07-00470.
The Tax Relief and Health Care Act of 2006 mandated that the Office of Inspector General (OIG) report to Congress the incidence of "never events" among Medicare beneficiaries, payment by Medicare for services in connection with such events, and the process used to identify events and deny payments. This report addresses that mandate by providing a descriptive analysis of the key issues to understanding hospital-based adverse events. The report is focused around discussion of seven critical issues that are explored in detail. Of note, OIG expanded the study of never events to the broader topic of adverse events in their analysis.