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- Commentary 1406
- Review 423
- Study 2653
- Image/Poster 12
- Slideset 10
- Book/Report 354
- Legislation/Case Law 6
- Newspaper/Magazine Article 643
- Newsletter/Journal 23
- Special or Theme Issue 127
- Toolkit 83
- Forum 2
- Award 50
- Bibliography 7
- Clinical Guideline 17
- Grant 21
United States Meeting/Conference
- South Region Meeting/Conference 6
- United States Meeting/Conference 11
- Upcoming Meeting/Conference 14
- Press Release/Announcement 118
Communication between Providers
- Sbar 27
- Communication between Providers 883
Culture of Safety
- Just Culture 28
Education and Training
- Simulators 155
- Students 93
Error Reporting and Analysis
- Error Analysis 811
- Error Reporting 684
Human Factors Engineering
- Checklists 204
Legal and Policy Approaches
- Regulation 91
- Logistical Approaches 388
- Policies and Operations 38
Quality Improvement Strategies
- Benchmarking 86
- Reminders 42
- Six Sigma 11
- Research Directions 42
Specialization of Care
- Hospitalists 22
- Teamwork 378
- Clinical Information Systems 601
- Telemedicine 24
- Transparency and Accountability 32
- Alert fatigue 27
- Device-related Complications 235
- Diagnostic Errors 462
Discontinuities, Gaps, and Hand-Off Problems
- Missed Care 11
- Drug shortages 31
- Failure to rescue 13
- Fatigue and Sleep Deprivation 156
- Identification Errors 122
- Inpatient suicide 8
- Interruptions and distractions 76
- Delirium 7
- Medication Errors/Preventable Adverse Drug Events 1262
- MRI safety 11
- Nonsurgical Procedural Complications 138
- Overtreatment 29
- Psychological and Social Complications 384
- Second victims 39
- Surgical Complications 641
- Transfusion Complications 15
- Home Care 56
- Operating Room 558
- General Hospitals 1356
- Long-Term Care 97
- Outpatient Surgery 68
- Patient Transport 38
- Psychiatric Facilities 22
- Allied Health Services 16
- Dentistry 12
- Anesthesiology 185
- Critical Care 313
- Dermatology 25
- Family Medicine 129
- Gynecology 40
- Cardiology 75
- Geriatrics 149
- Hematology 23
- Medical Oncology 116
- Nephrology 23
- Pulmonology 16
- Neurology 36
- Obstetrics 152
- Pediatrics 502
- Primary Care 213
- Radiology 124
- Home Nursing 13
- Palliative Care 4
- Pharmacy 735
- Family Members and Caregivers 89
Health Care Executives and Administrators
- Nurse Managers 697
- Risk Managers 515
Health Care Providers
- Nurses 1008
- Pharmacists 528
- Physicians 1676
Non-Health Care Professionals
- Educators 561
- Engineers 101
- Media 17
- Policy Makers 323
- Patients 427
- Africa 2
- China 3
- Australia and New Zealand 19
- Central and South America 2
- Europe 59
- Canada 36
United States of America
United States Federal Government
- Department of Health and Human Services (HHS) 426
- United States Federal Government 584
Search results for ""
Award > Award Announcement
Institute for Safe Medication Practices.
The Institute for Safe Medication Practices sponsors the annual Cheers Awards to recognize both individuals and institutions for their commitment to medication safety. The process for submitting a nomination is currently closed.
Tufts-New England Medical Center, Tufts University School of Medicine, and Harvard University: Center for Quality Assessment & Improvement in Mental Health; 2011.
This website provides a searchable database of process measures for quality assessment and improvement in mental health and substance abuse care. It includes more than 300 measures with specifications drawn from developer source materials.
Tools/Toolkit > Fact Sheet/FAQs
Rockville, MD: Agency for Healthcare Research and Quality; 2000. AHRQ Publication 00-PO58.
This fact sheet on medical errors provides information based on current research. Patients at risk, types of medical errors, and ways to improve and promote patient safety are discussed. References to programs and publications on medical errors and patient safety are provided.
Stucky ER. Pediatrics. 2003;112:431-436.
Key areas of recommendations to improve medication safety are reviewed: hospital-wide system actions and guidelines, prescriber actions and guidelines, and education and communication for prescribers, nurses, pharmacists, patients, and families.
Fivars G, Fitzpatrick R. Pittsburgh, PA; 2001.
A research tool to identify critical requirements for performance in applied areas of psychology and behavioral science. This technique, used in anesthesia to understand failures (see also Cooper et al. 1978 and Flanagan 1954), represents one methodology adopted from non-medical arenas to study patient safety.
Swidey N. Boston Globe. January 4, 2004.
An introduction to Donald Berwick, CEO of Boston's Institute for Healthcare Improvement, and his vision for reshaping health care to improve patient safety and quality.
Web Resource > Database/Directory
Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services, 2003.
This web-accessible database provides access to evidence-based quality measures and measure sets. The mission of the National Quality Measures Clearinghouse (NQMC) is to provide practitioners, health care providers, health plans, integrated delivery systems, purchasers, and others an accessible mechanism for obtaining detailed information on quality measures and to further their dissemination, implementation, and use in order to inform health care decisions.
This website is a practical resource to review existing clinical practice guidelines in a centralized location. Key components of the site include links to full-text guidelines and an assessment function that explores the rigor and trustworthiness of each document. This website was built by the team that developed and maintained the AHRQ National Guideline Clearinghouse, which is no longer available.
Training of Hospital Staff To Respond to a Mass Casualty Incident. Summary, Evidence Report/Technology Assessment.
Hsu EB, Jenckes MW, Catlett CL, et al. Summary, Evidence Report/Technology Assessment: Number 95. Rockville, MD: Agency for Healthcare Research and Quality; April 2004. AHRQ Publication Number 04-E015-1.
This report focuses on the effectiveness of hospital disaster drills, computer simulations, and tabletop or similar exercises in training hospital staff to respond to a mass casualty incident (MCI).
Tools/Toolkit > Measurement Tool/Indicator
AHRQ Quality Indicators. Rockville, MD: Agency for Healthcare Research and Quality; September 2005.
The Agency for Healthcare Research and Quality's (AHRQ) Quality Indicators (QIs) represent quality measures that make use of a hospital's available administrative data. The Inpatient Quality Indicators include inpatient mortality for certain procedures and medical conditions; utilization of procedures for which there are questions of underuse, overuse, and misuse; and volume of procedures for which evidence suggests that a higher volume is associated with lower mortality.
Agency for Healthcare Research and Quality.
This online newsletter announces Agency for Healthcare Research and Quality (AHRQ) products and projects and summarizes research findings from agency-supported studies.
Journal Article > Commentary
Weick KE. Adm Sci Q. 1993;38:628-652.
This article is a review and analysis of the Mann Gulch fire disaster, an event made famous in Norman Maclean's award–winning book, Young Men and Fire (1992). Using the story of a firefighter who improvised a response to a fire by setting a back-fire while the rest of his crew panicked and ultimately perished, Weick examines the disintegration of role structure and sensemaking within an organization. He discusses sources of resilience that make groups less vulnerable, including improvisation, virtual role systems, the attitude of wisdom, and norms of respectful interaction. The purpose is to understand why organizations unravel and how they become more resilient. The organizational literature is reviewed to demonstrate a need for reexamination of successful group structures. Weick's work influenced many others who have written about improving safety, particularly in teams that work in fast-moving and ambiguous clinical settings.
The Effect of Health Care Working Conditions on Patient Safety. Evidence Report/Technology Assessment.
Evidence Report/Technology Assessment: Number 74. Rockville, MD: Agency for Healthcare Research and Quality; March 2003. AHRQ Publication No. 03-E024.
This report summarizes existing scientific evidence on the role health care working conditions play in patient safety efforts.
Legislation/Regulation > Organizational Policy/Guidelines
American Society of Hospital Pharmacists. Am J Hosp Pharm. 1993:50:305-314.
Strategies to prevent inpatient medication errors are discussed, including their connection to existing hospital infrastructure designed with overlapping goals (e.g., Pharmacy and Therapeutics Committees).
Web Resource > Database/Directory
Tucson, AZ: University of Arizona Center for Education and Research on Therapeutics, Arizona Health Sciences Center; 2010.
This tool identifies drugs that affect the cardiac conduction system in a deleterious fashion.
Legislation/Regulation > Database/Directory
Bethesda, MD: American Society of Health-System Pharmacists.
This searchable listing of the American Society of Health-System Pharmacists policy and guideline collection provides user access to various content areas relevant to safe inpatient medication administration. The 2018 enhancements include a revision of the "ASHP Guidelines on Preventing Medication Errors in Hospitals".
Web Resource > Forum
Institute for Healthcare Improvement.
A collection of moderated multidisciplinary and multicultural discussion groups that provide both clinical and administrative insights that relate to patient safety improvement.
Journal Article > Study
Cooper JB, Newbower RS, Long CD, McPeek B. Anesthesiology. 1978;49:399-406.
This study reports on the retrospective analysis of nearly 360 preventable incidents at an urban teaching institution and was a first in using human factors research methods in an anesthesia setting. To determine patterns of failure in anesthetic practice, the investigators conducted interviews with staff and anesthesiologists before performing a critical-incident analysis. This methodology aims to translate anecdotal experiences into systematic study of human performance. Findings attributed the majority of incidents to human error, with a relatively small percentage due to pure equipment failure. The authors suggest that their method of examining incidents may be effective to help pool similar data from other institutions and design system strategies for prevention.
Journal Article > Commentary
Pierce EC. Anesthesiology. 1996;29:965-975.
In this article based on a special lecture delivered at the 1995 annual meeting of the American Society of Anesthesiologists (ASA), the author provides an historical perspective on the birth of patient safety in the field of anesthesia. From personal anecdotes in the operating room to descriptions of emerging research around postoperative deaths, the presentation provides a unique perspective on the gradual emergence of safety efforts in anesthesia. In addition, Pierce discusses the factors that led him to develop the first ASA Committee on Patient Safety and Risk Management, host the first International Symposium on Preventable Anesthesia Mortality and Morbidity, and form the Anesthesia Patient Safety Foundation. Pierce closes by introducing the challenges that lie ahead in balancing the commitment to safety with the growing climate of cost-containment and productivity.
Journal Article > Review
Anesthesia safety: model or myth? A review of the published literature and analysis of current original data.
Lagasse RS. Anesthesiology. 2002;97:1609-1617.
The Committee on Quality of Health Care in America for IOM anointed the area of anesthesia as a model for safety improvements. This study examines those claims by conducting a literature review of anesthesia-related mortality rates from 1966 to 2000. The author also analyzes recent perioperative mortality data collected from two university-based practices. Results from aggregate data, as well as mortality rates determined by peer review, suggest that, contrary to commonly held beliefs, mortality has remained relatively stable in recent decades. However, considerable variability exists due to different operational definitions and reporting sources. Lagasse, while crediting the field of anesthesiology with many safety advances, concludes that insufficient evidence exists to support the reported decline in anesthesia-related mortality. He suggests that standardization of data collection methods and analysis is needed to effectively identify and measure best practices.