Narrow Results Clear All
- Communication Improvement 6
- Culture of Safety 2
- Education and Training 6
- Error Reporting and Analysis 20
- Human Factors Engineering 4
- Legal and Policy Approaches
- Logistical Approaches 3
- Quality Improvement Strategies 10
- Teamwork 2
- Technologic Approaches 1
- Transparency and Accountability 2
- Device-related Complications 3
- Diagnostic Errors 3
- Discontinuities, Gaps, and Hand-Off Problems 2
- Drug shortages 1
- Fatigue and Sleep Deprivation 2
- Identification Errors 1
- Medical Complications 17
- Medication Safety 6
- Nonsurgical Procedural Complications 1
- Psychological and Social Complications 3
- Surgical Complications 7
- Transfusion Complications 2
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Journal Article > Commentary
Medication errors in family practice, in hospitals and after discharge from the hospital: an ethical analysis.
Clark PA. J Law Med Ethics. 2004;32:349-357.
In this article, the author urges the medical community to universally apply the systems approach to safety toward the reduction of medical errors. The author calls for health care to take medication errors more seriously and for patients to help drive improvement.
Kapadia R. Smart Money. October 2006;15:112-114.
This article provides tips for consumers to help keep their hospital care as safe and hassle-free as possible.
Zimmerman R. Wall Street Journal. February 6, 2007:A1.
This article reports on a mother's campaign to educate parents about kernicterus and to make bilirubin tests standard for all newborns.
Victoria Times Colonist. March 26, 2007.
This article reports on findings from an investigation into hospital-acquired infections in British Columbia.
Golden, CO: HealthGrades, Inc.; April 2007.
This fourth annual report on the safety of hospitalized Medicare patients builds on past efforts to evaluate hospital performance. The report uses the Agency for Healthcare Research and Quality's Patient Safety Indicators to provide benchmarks for such performance, identify current trends in safety issues, and estimate preventable events nationally. The report suggests that the patient safety incidents captured account for nearly $9 billion in excess cost during 2003-2005, and nearly 250,000 potentially preventable deaths occurred during the same time period. Grading for all states and a selected group of highly rated hospitals is included with the implication that, if all hospitals performed at a level comparable to the ones acknowledged, more than 34,000 Medicare deaths could be avoided with a cost savings of $1.74 million. As with the second and third annual reports, several methodological limitations exist, and the reports themselves did not receive external peer review.
Pear R. New York Times. August 19, 2007.
This article reports on a new Centers for Medicare and Medicaid Services (CMS) rule mandating that Medicare will no longer pay for treating certain preventable errors starting in 2008, including some hospital-acquired infections, decubitus ulcers, and retained foreign bodies. The policy is generating considerable discussion in patient safety circles, with some expressing concerns regarding the economic impact on hospitals and the increased efforts it is likely to create for hospitals to document certain patient problems present at the time of admission.
Kershaw S. New York Times. Sepember 7, 2007;Metro Desk section:B1.
This article reports on an initiative to publish data on mortality and hospital-acquired infections in New York City public hospitals.
Kowalczyk L. Boston Globe. September 17, 2007;Metro section:1A.
This article reports on how numerous Massachusetts hospitals have implemented policies to waive charges for the set of serious errors categorized as never events.
Lerner M. Star Tribune. September 18, 2007;News section:5B.
This article reports on Minnesota's adoption of a policy for hospitals to not charge patients or insurers for never events or consequent treatment.
Fuhrmans V. Wall Street Journal. January 15, 2008:D1.
This article reports on health insurance companies adopting the tactic of not paying for preventable errors, which parallels a similar federal decision.
More states shred bills for awful medical errors: patients in 23 states will no longer pay for certain mistakes, hospitals say.
Aleccia J. MSNBC News. August 12, 2008.
This article reports on the implementation and expansion of several states' non-payment policies for medical mistakes in light of similar policies set by Medicare and private insurance companies.
Kowalczyk L. The Boston Globe. August 10, 2008;Metro section:1A.
This article describes how physician outbursts can affect patient safety and discusses a new Joint Commission policy that supports actions against providers who engage in disruptive behavior.
Greene L. St. Petersburg Times. August 19, 2008.
This article reports on recent apologies made by Florida hospital officials for medical errors.
Golden, CO: HealthGrades, Inc.; April 2009.
This analysis of patient safety in Medicare patients from 2005–2007 concludes that while modest improvements have been made, patient safety incidents still account for nearly 100,000 preventable deaths and nearly $7 billion in excess costs yearly. The report also recognizes the best performing hospitals with a "Patient Safety Excellence Award"—hospitals scoring in the top 15% according to a ranking methodology developed by the authors. As with prior HealthGrades reports, the study uses the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSIs) to measure the incidence of patient safety problems and compare hospitals. The limitations of using PSIs as a performance measure have been discussed in a prior study and AHRQ WebM&M commentary, and it is important to note that this report did not undergo external peer review.
Rein L. Washington Post. July 21, 2009:E1.
This news article reports on Washington, DC–area initiatives to track preventable patient injury and discusses strategies to hold hospitals accountable to reduce the number of avoidable incidents.
Landro L. Wall Street Journal. August 25, 2009:D1.
This column shares the experience of hospitals and families whose involvement in open disclosure has resulted in improved care, reduced litigation costs, and patient partnerships.
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.
Austin, TX: Texas Medical Institute for Technology and the Quaid Foundation; 2010.
This documentary reports on families affected by medical errors; it includes the story of a high-profile heparin overdose and how it transformed the family of actor Dennis Quaid into advocates for patient safety.
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.
Valencia MJ. Boston Globe. March 10, 2011.
This newspaper article reports on a fatal medication error involving an anticoagulant overdose.
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.
PBS News Hour. April 12, 2011.
Moss-Coane M, O'Connell K, Fishman N. Radio Times. April 28, 2011.
This radio program featured interviews with an infectious disease specialist and a patient who contracted a hospital-acquired infection, and discussed how patients and providers can reduce their occurrence.
McFadden C. ABC News Nightline. March 6, 2013.
Brown T. New York Times. March 17, 2013:SR5.
Howard B. AARP The Magazine. April/May 2013;56:46-50,52,71.
This magazine article details how several hospitals have taken a comprehensive approach to improving patient safety in their organizations. An interactive graphic displays many of the methods being used; an accompanying tool lists hospitals and their safety features.
Chen PW. New York Times. April 18, 2013.
Teegardin C. Atlanta Journal-Constitution. April 28, 2013.
Hartcollis A. New York Times. May 29, 2013:A18.
This newspaper article reports on efforts, such as remote video monitoring or distributing "red cards," to improve hand hygiene compliance in hospitals.
Allen M. ProPublica. September 19, 2013.
Harrow, Middlesex, UK: The Patients Association; 2013.
This publication provides patient and family accounts of incidents involving inadequate care or harm and highlights the need for improvements recommended in a National Health Services report.
Levey NN. Los Angeles Times. October 4, 2011.
This newspaper article reports on improving US health care and profiles Dr. Donald Berwick, highlighting his commitment and contributions to patient safety and quality work.
Audiovisual > Audiovisual Presentation
Faye J. NBC-17 News. November 10, 2011.
This news segment discusses how drug shortages can affect providers, patients, and decisions about medication therapy.
Journal Article > Study
Hinchcliff R, Westbrook J, Greenfield D, Baysari M, Moldovan M, Braithwaite J. Int J Qual Health Care. 2012;24:1-8.
Vaida B. The Washingtonian. January 27, 2012.
This magazine article discusses patient safety improvement efforts as well as challenges hindering more widespread error reduction.
Rau J. Washington Post. February 12, 2012:A03.
This news article describes problems with analyzing data from a 2011 report on hospital-acquired conditions to accurately measure a hospital's overall quality of care.
Journal Article > Study
High-profile investigations into hospital safety problems in England did not prompt patients to switch providers.
Laverty AA, Smith PC, Pape UJ, Mears A, Wachter RM, Millett C. Health Aff (Millwood). 2012;31:593-601.
While medical errors continue to affect patients on a daily basis, most organizations fear high-profile cases that land on front pages of newspapers or lead to extensive regulatory intervention. This study evaluated the role of England's Care Quality Commission in their own regulatory investigation of major issues occurring in three hospitals. The investigations led to considerable media attention, but whether this influenced patient behavior was unknown. The authors found that the investigations had zero impact on utilization at two of the hospitals. The third experienced a decrease in inpatient admissions and new patient visits, but the effect dissipated 6 months following the public report. In an era of greater transparency and increased attention on patient safety, these findings suggest that patients' decision-making is perhaps less influenced than expected by such events. Two past AHRQ WebM&M perspectives discussed organizational change in the face of highly public errors at Duke and the Dana Farber Cancer Institute.
Greider K. AARP Bulletin. March 2012;53:10,12,14.
Gupta S. New York, NY: Grand Central Publishing; 2012. ISBN: 9780446583855.
To illustrate how physicians learn from mistakes, this novel (written by CNN medical correspondent Dr. Sanjay Gupta) explores the impact of a medical error on surgeons at one hospital.
Landro L. Wall Street Journal. June 5, 2012;D1.
This newspaper article describes how one hospital reduced hospital-acquired infection rates.
Hartocollis A. New York Times. July 28, 2012.
This newspaper article reports on the missteps that contributed to the death of a young woman after she was hospitalized in an incident reminiscent of Libby Zion.
Terhune C. Los Angeles Times. August 3, 2012:B1.
This newspaper article reports on an incident during which dozens of hospitals lost access to electronic medical records (EMRs) and discusses risks associated with EMR systems.
Eisler P. USA Today. August 16, 2012.
This newspaper article reports on how clinicians, hospitals, and health care systems can reduce incidence of hospital-acquired Clostridium difficile infections.
Kolata G. New York Times. August 22, 2012.
Despite strict infection controls placed around a patient carrying a deadly antibiotic-resistant bacteria, 17 other patients also became infected and 6 died. This newspaper article details the approach used to track the chain of transmission.
Sternberg S. US News & World Report. August 28, 2012.
This magazine article discusses insights from experts and patients on how to prevent errors in hospitals in the United States.
Kane J. PBS NewsHour. October 23, 2012.
This video reveals how checklists can help patients and their families ensure safety during hospital care.
Hartocollis A, Bernstein N. New York Times. November 2, 2012:A1.
Reporting on power outages and flooding that hospitals faced following a strong hurricane, this newspaper article describes how health systems worked to keep patients safe.
Kowalczyk L. Boston Globe. April 9, 2013.
This newspaper article describes how one hospital has fostered open communication about medical errors through a monthly newsletter that recounts mistakes in an effort to prevent them from recurring. Reports in the newsletter also solicit the involved patient's perspective.
Rosenbaum L. The New Yorker: Elements. August 20, 2013.
This magazine article relates the risks and benefits associated with the 2003 resident work hour limits.
Ryan J. All Things Considered. National Public Radio. October 16, 2013.
This radio news segment reports on patient falls, including risk factors and prevention strategies.
Department of Health. London, England: Crown Publishing; November 2013. ISBN: 9780101875424.
This report outlines actions that health care leaders in the United Kingdom have committed to take in order to address system problems identified by an inquiry into Mid Staffordshire National Health Services Foundation Trust.
Rosenberg T. New York Times. December 4, 2013.
Preventable adverse events may result in more harm than previously thought. Highlighting inconsistencies in publicly reported hospital safety data, this newspaper article explains how information is collected, analyzed, and presented by organizations such as Hospital Compare, Consumer Reports, and Leapfrog.