Narrow Results Clear All
- Review 3
- Study 21
- Audiovisual 1
- Book/Report 7
- Newspaper/Magazine Article 18
- Special or Theme Issue 1
- Tools/Toolkit 1
- Web Resource 7
- Award 5
- Grant 1
- Press Release/Announcement 2
- Communication Improvement 6
- Culture of Safety 7
- Education and Training 9
Error Reporting and Analysis
- Error Reporting 18
- Human Factors Engineering 1
Legal and Policy Approaches
- Regulation 11
- Logistical Approaches 3
- Quality Improvement Strategies 21
- Specialization of Care 1
- Teamwork 2
- Clinical Information Systems 6
- Transparency and Accountability 3
- Device-related Complications 2
- Diagnostic Errors 2
- Discontinuities, Gaps, and Hand-Off Problems 5
- Fatigue and Sleep Deprivation 2
- Medical Complications 21
- Medication Safety 6
- Surgical Complications 9
- Transfusion Complications 2
- Surgery 2
- Pharmacy 3
- Family Members and Caregivers 1
- Health Care Executives and Administrators 47
- Health Care Providers 19
Non-Health Care Professionals
- Media 1
- Patients 12
- Asia 1
- Australia and New Zealand 1
- Europe 2
- Canada 1
Search results for ""
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.
Journal Article > Study
Simon JS, Rundall TG, Shortell SM. J Am Med Inform Assoc. 2007;14:432-439.
The authors surveyed primary care medical groups and found that only 27% have electronic order entry with decision support for chronic disease care. External quality incentives were associated with driving adoption of such tools.
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.
Journal Article > Study
Publicly available hospital comparison web sites: determination of useful, valid, and appropriate information for comparing surgical quality.
Leonardi MJ, McGory ML, Ko CY. Arch Surg. 2007;142:863-869.
The growing focus on health care quality has led to the development of several Web sites that make hospital quality information publicly available to consumers. This study evaluated six such Web sites (the Centers for Medicaid and Medicare Services' Hospital Compare, the Joint Commission's Quality Check, the Leapfrog Group, and three commercial sites) for ease of use, data accuracy, and consistency of hospital rankings for several surgical quality measures. In general, the governmental and non-profit Web sites were rated as easier to use and had more complete information. However, the authors found significant variation in the risk adjustment methods used and the types of outcomes reported on each Web site, leading to poor reproducibility of rankings for specific surgical procedures.
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.
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.
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.
Journal Article > Study
Li P, Schneider JE, Ward MM. Health Serv Res. 2007;42:2089-2108.
Carpenter D. Hosp Health Netw. November 2007;81:34-38.
Wilson B. Am Med News. November 26, 2007:50:16.
This article explores the recent trend of hospitals tying senior management compensation and incentives to mortality rates and compliance with safety measures.
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.
Golden, CO: HealthGrades, Inc.; April 2008.
This analysis of patient safety in Medicare patients from 2004-2006 concludes that while modest improvements have been made, patient safety incidents still account for more than 200,000 preventable deaths and nearly $9 billion in excess costs yearly. The report identifies "Distinguished Hospitals for Patient Safety"—the 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 and Research 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.
O'Reilly KB. American Medical News. May 12, 2008.
This article reports that the Centers for Medicare and Medicaid Services (CMS) has proposed expanding the list of hospital-acquired conditions that it will no longer cover.
NY Medicaid ups the ante: by refusing to pay for 14 'never events,' the nation's biggest Medicaid program could propel other states into action.
DerGurahian J. Mod Healthc. June 16, 2008;38:6.
Journal Article > Study
Brand CA, Tropea J, Ibrahim JE, et al. Med J Aust. 2008;189:35-40.
Australian hospitals are using a wide variety of measurement tools to evaluate patient safety, including both process measurement and quantitative measurement methods.
Chicago, IL. American Hospital Association; July 24, 2008.
This announcement and accompanying magazine insert profiles recipients of the 2008 American Hospital Association Quest for Quality Prize, an annual award that honors hospitals demonstrating achievement in the six Institute of Medicine quality aims: safety, effectiveness, efficiency, patient-centeredness, timeliness, and equity.
O'Reilly KB. American Medical News. August 11, 2008;51:1.
This article reports on hospital officials' public admissions of error and discusses the potential impact of these disclosures on patient safety.
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.
Greene L. St. Petersburg Times. August 19, 2008.
This article reports on recent apologies made by Florida hospital officials for medical errors.
Neary L. "Talk of the Nation." National Public Radio. August 26, 2008.
This radio interview features Donald Berwick and Robert Wachter discussing how Web sites reporting national hospital data can drive improvement and safety.