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Perspectives on Safety > Perspective
Organizational Change in the Face of Highly Public Errors—I. The Dana-Farber Cancer Institute Experience
with commentary by James B. Conway; Saul N. Weingart, MD, PhD, Errors in the Media and Organizational Change, May 2005
A decade ago, two tragic medical errors rocked one of the world’s great cancer hospitals, Dana-Farber Cancer Institute (DFCI) in Boston, to its core. The errors led to considerable soul searching and, ultimately, a major change in institutional practices a...
Perspectives on Safety > Perspective
with commentary by Rosemary Gibson, MSc, The Patient's Role in Safety, March 2007
Patients have three roles in improving patient safety: helping to ensure their own safety, working with health care organizations to improve safety at the organization and unit level, and advocating as citizens for public reporting and accountability of hospital and health system performance. The following case illustrates how patients can help ensure their own safety.
Weise E. USA Today. May 18, 2005.
Wojcieszak D. Patient Safety Qual Healthc. May/June 2005;2:6, 8-9.
The author, who lost his brother to medical error, reflects on his family's frustrating experience with the hospital and legal system. He proposes that the medical profession can learn valuable lessons from the engineering safety culture.
Toward a High Performance Health System: Public-Private Efforts to Make Health Care Safer and More Effective.
Washington, DC: Alliance for Health Reform, The Commonwealth Fund; 2005.
This briefing featured a moderated panel discussion on health care issues such as performance, insurance coverage, quality, and public and private sector roles in promoting change. The HealthCast, provided by kaisernetwork.org, is available in video, audio, and transcript formats.
Wolosin R, Vercler L, Matthews J. Patient Safety & Quality Healthcare. November/December 2005;2:40-44.
The authors examined patients' perceptions of safety in hospital settings and factors that affect their perceptions.
Journal Article > Study
Stebbing C, Kaushal R, Bates DW. Pediatrics. 2006;117:1907-1914.
This study analyzed newspaper coverage of pediatric medication errors and adverse drug events in five countries to demonstrate increased interest in the topic over the past decade. Investigators examined the number of articles and the types of events covered and assessed the overall themes presented and framed by the media. The majority of articles published covered patient incidents followed by policy and then research in decreasing order of frequency. Despite the occasional occurrence of sensational reporting on errors, more than 70% of articles that were deemed to be negatively associated with patient safety were covered in a neutral manner.
Four Corners. ABC Television. July 3, 2006.
This Web site on an Australian documentary provides links to resources and an online forum discussing patient safety.
Learning from Bristol: The Report of the Public Inquiry into Children's Heart Surgery at the Bristol Royal Infirmary 1984–1995.
London, England: The Stationery Office; July 2001.
In June 1998, the Secretary for Health announced to Parliament the organization of a formal Inquiry into children's heart surgery at the Bristol Royal Infirmary between 1984 and 1995. Their objectives included understanding what happened in Bristol, assessing the quality of care and system failures that contributed to deaths, and generating lessons that could be learned for the entire National Health Service (NHS) in the United Kingdom. The inquiry was independent and not held as a legal proceeding, but provided a comprehensive investigation with interviews, expert panels, and a goal of driving improvement efforts. Section one of the report outlines pediatric cardiac surgical services in Bristol while section two focuses on recommendations to ensure high quality care across the NHS. Several publications resulted from the learnings of the Bristol inquiry, including a discussion of cultural entrapment and lessons for quality improvement.
Audiovisual > Audiovisual Presentation
Kurtis B. New York Times. A&E Television Networks; 2008.
This 40-minute news feature interviews patients and others about clinical errors, inappropriate care, ineffective peer review, and systemic improvement in health care.
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.
Schulz K. Slate.com. June 28, 2010.
This discussion with the head of the National Center for Patient Safety reveals insights on reliability, reporting, and system improvement gleaned from his career in high-risk industries.
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.
Canadian Patient Safety Institute and Health Standards Organization.
This draft 5-year framework aims to guide the activities in Canada to focus action, resources, and policy development on supporting care improvement. The document is structured around five goals: people-centered care, safe care, accessible care, appropriate care, and continuous care. The authors invited Canadian patients, families, clinicians, organization leaders, and policymakers to provide input on the material to ensure its applicability across the country.