Narrow Results Clear All
- Communication Improvement 1
- Education and Training 1
- Error Reporting and Analysis 5
- Legal and Policy Approaches
- Quality Improvement Strategies 3
- Technologic Approaches 1
- Transparency and Accountability 1
- Identification Errors 1
- Medication Safety 2
- Nonsurgical Procedural Complications 1
- Psychological and Social Complications 1
- Surgical Complications 4
Search results for ""
Journal Article > Study
Public reporting of antibiotic timing in patients with pneumonia: lessons from a flawed performance measure.
Wachter RM, Flanders SA, Fee C, Pronovost PJ. Ann Intern Med. 2008;149:29-32.
Efforts to improve the quality and safety of care are being driven in part by a growing focus on public reporting. This commentary shares the potential for the unintended consequences of reporting on flawed performance measures, using time to first antibiotic dose (TFAD) in patients with pneumonia as an example. The authors discuss the background data for this particular quality measure, how it was translated into a performance standard, and the response it generated from emergency departments as well as payers, regulators, and professional societies. The authors conclude with a number of lessons learned from this case example, including the tension that results from having providers balance their desire to do the right thing with the public's view of their quality of care when they are in conflict with each other. A past AHRQ WebM&M commentary discussed the unintended consequences of achieving a good report card on such measures.
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.
Grant M. AARP The Magazine. September/October 2010;53:48-51,90-91.
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.
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.