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Stock S, Putnam J, Carroll J, Pham S. NBC Bay Area. November 19, 2014.
Hospital reporting of errors in the United States has been suboptimal. This news video investigates the effectiveness of a state reporting initiative in California. Although hospitals have reported 6282 adverse events to the state in 4 years, patient safety experts suggest that those results do not reliably represent all the incidents that should have been submitted.
Eisler P, Hansen B. USA Today. August 20, 2013.
This newspaper article reports on physicians with records of misconduct and how poor oversight for monitoring and discipline allows them to continue practicing medicine.
Oakbrook Terrace, IL: Joint Commission.
The Joint Commission's annual report summarizes hospital performance across a broad range of metrics that represent evidence-based standards for high-quality care. These accountability measures have been shown to be directly linked to patient outcomes. Since the report's first publication in 2007, data demonstrates that hospitals have measurably improved quality of care for heart attacks, pneumonia, surgical care, children's asthma care, inpatient psychiatric services, venous thromboembolism, and stroke patients.
Hospira Carpuject pre-filled cartridges—drug alert: products may contain more than the intended fill volume.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; May 23, 2012.
This announcement raises awareness of pre-filled medication cartridges that may be overfilled, thereby increasing the risk of overdose. The FDA recommends that practitioners confirm the dosage prior to dispensing and administering the medication.
Journal Article > Study
Iedema R, Allen S, Sorensen R, Gallagher TH. Jt Comm J Qual Patient Saf. 2011;37:409-417.
This Australian study used interviews with clinicians, patients, and families to identify a wide range of barriers to disclosing adverse events. The article provides specific guidance for clinicians, risk managers, and policymakers to promote full disclosure of adverse events.
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.
Weinstock M. Hosp Health Netw. 2011 Apr;85:46-49, 2.
This article discusses one hospital system's effort to hardwire safety into daily work by having providers look at each patient as a loved one.
Ginsburg M, Glasmire K. Oakland, CA: California HealthCare Foundation; April 2011.
Examining consumers' opinions on health care quality and safety, this report offers recommendations for hospitals to prioritize improvement efforts.
Web Resource > Government Resource
Agency for Healthcare Research and Quality.
This Web site provides tools to help organizations create and distribute quality of care reports to consumers.
Web Resource > Multi-use Website
This organization rates online health care report cards and provides tips for reporting quality concerns.
Allen M. Washington Monthly. March/April 2011.
This magazine article reports on medical errors in the United States health care system and discusses transparency as a tactic to improve patient safety.
Bogdanich W, Rebelo K. New York Times. December 28, 2010;A1.
This article explores inaccuracy of dosage, lack of protocol adherence, and absence of transparency as trends that hinder learning from radiological adverse events.
Grant M. AARP The Magazine. September/October 2010;53:48-51,90-91.
Allen M, Richards A. Las Vegas Sun. June 27, 2010.
This news series reports on an investigation that included hospital record review and interviews with stakeholders to explore the quality and safety of health care in Las Vegas.
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.
Leape LL. Perspect Health Reform. New York, NY: The Commonwealth Fund; March 17, 2010.
Of three approaches to enhancing patient safety—regulation/accreditation, financial incentives, and public reporting—this perspective, written by the father of the modern patient safety movement, details how public reporting holds the most potential to stimulate improvement.
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.
Wright S. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; January 5, 2010. Report No. OEI-06-09-00360.
Kauffman M, Altimari D. The Hartford Courant. November 15, 2009;Final:A1.
This newspaper article reports that a Connecticut law intended to make hospital errors more transparent has had the opposite effect by making it easier for hospitals to limit publicly available information on adverse events.
Perspectives on Safety > Perspective
with commentary by Robert M. Wachter, MD, The Role of the Media in Patient Safety, October 2009
December 1 marks the tenth anniversary of the Institute of Medicine (IOM) report To Err Is Human, the blockbuster that launched the modern patient safety movement.(1) The anniversary provides an opportunity to reflect on the forces that have promoted safety efforts over the past decade. They include a more robust accreditation environment, increased reporting of adverse events to state and other regulatory bodies, growing implementation of information technology, skill-building support by organizations such as Institute for Healthcare Improvement, and a maturing research field supported by AHRQ and others.