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- Perspectives on Safety 1
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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...
Doctor’s orders killed cancer patient: Dana-Farber admits drug overdose caused death of Globe columnist, damage to second woman.
Knox RA. The Boston Globe. March 23, 1995; Metro/Region section: 1.
This column chronicles the tragic death of Betsy Lehman, a Boston Globe health columnist, who fell victim to an inadvertent overdose of chemotherapy while receiving treatment for breast cancer at the Dana-Farber Cancer Institute. The story details the events surrounding the case, the reactions among family and the public, and the response from Dana-Farber.
Weber T, Ornstein C. Los Angeles Times. April 12, 2005.
This article reports on a death that occurred at the Martin Luther King Jr./Drew Medical Center after a patient's deteriorating vitals signs went unnoticed.
King K. Silicon Valley/San Jose Business Journal. April 15, 2005: In Depth: Structures section.
The vice president of facilities at El Camino Hospital discusses the opportunity for building a facility that will improve patient care and employee productivity.
Legislation/Regulation > Federal Legislation
S 1337, 109th Cong, 1st Sess (Mt 2005).
This bill was introduced in the U.S. Senate to encourage alternatives to the current medical malpractice system (by creating a "health care court") and to promote early disclosure and resolution of medical errors.
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.
Edmonton, AB: Canadian Patient Safety Institute; December 2, 2005.
This news release announces the selection of 28 research and demonstration projects eligible for funding from the Canadian Patient Safety Institute research initiative.
Web Resource > Multi-use Website
10235 101 Street, Suite 1414, Edmonton, AB, Canada T5J 3G1.
The Canadian Patient Safety Institute (CPSI) fosters collaboration between governments and stakeholders in developing patient safety initiatives. This Web site provides tools for health care professionals and patients.
Journal Article > Commentary
Clinton HR, Obama B. N Engl J Med. 2006;354:2205-2208.
This commentary is written by Senators Hillary Rodham Clinton (D-NY) and Barack Obama (D-IL), who coauthored the National Medical Error Disclosure and Compensation (MEDiC) Act. Providing context for the bill, the senators advocate for necessary improvements in patient safety and the medical liability environment through a series of important and interdependent strategies. These include reducing the rates of preventable patient injuries, promoting open communication between physicians and patients, ensuring patients' access to fair compensation for legitimate medical injuries, and reducing liability insurance premiums for providers. The senators further discuss the implications of each approach and specifically outline the major provisions of the bill, including how it will foster and promote the necessary improvement efforts.
Scobie S, Minghella E, Dale C, Thomson R, Lelliott P, Hill K. London, UK: National Patient Safety Agency; July 2006.
This report, the second in a series from the United Kingdom's National Patient Safety Agency, analyzes nearly 45,000 patient safety incidents relating to mental health that were reported to a nationwide incident reporting system. The majority of reported incidents were from inpatient mental health facilities, primarily involving patient accidents (including falls), disruptive or aggressive behavior, self-harming behavior, and missing (absconding) patients. The report summarizes existing initiatives to improve patient safety in mental health, makes specific recommendations for mental health providers, and identifies priority areas for future research.
Journal Article > Commentary
Emanuel EJ. JAMA. 2007;297:2131-2133.
The author discusses how changes in language used to describe health care reflect a shifting public perception of the US health care system. This shift involves increasing recognition that errors do occur and that the health care system is flawed.
Healthcare Commission. London, England: Commission for Healthcare Audit and Inspection; 2008. ISBN: 9780102958362.
This report assesses care in the United Kingdom, provides data on a variety of issues related to safety, and makes recommendations to support improvements over time.
The Joint Commission.
The Eisenberg Award honors individuals and organizations who have made vital accomplishments in improving patient safety and quality. The 2009 honorees are Gary Kaplan, MD; Tejal Gandhi, MD; The Keystone Center for Patient Safety; Mercy Hospital Anderson (Cincinnati, Ohio); and Noreen Zafar, MD.
Washington, DC: Leapfrog Group; December 4, 2009.
This news announcement highlights the 45 urban, children's, and rural hospitals recognized for highly efficient performance and continuous improvement in patient safety based on the 2009 Leapfrog Hospital Survey results.
Rockville, MD: Agency for Healthcare Research and Quality.
In this annual publication, AHRQ reviews the results of the National Healthcare Quality Report and National Healthcare Disparities Report. Providing a 5-year update on the National Quality Strategy, this report highlights that a wide range of quality measures have shown improvement in quality, access, and cost.
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.
Utrecht, Netherlands: European Network for Patient Safety; 2010.
This report identifies care process and outcome indicators in the European Union and describes how the indicators relate to patient safety culture.
Web Resource > Multi-use Website
International Society for Quality in Health Care.
This Web site provides access to communities of practice, online learning activities, and discussions exploring safety and quality.
ISMP Medication Safety Alert! Acute Care Edition. October 18, 2012;17:1-4.
This piece reviews risks associated with the use of compounding pharmacies and recommends that legislative oversight can improve medication safety.
Journal Article > Study
Interactive effects of nurse-experienced time pressure and burnout on patient safety: a cross-sectional survey.
Teng CI, Shyu YI, Chiou WK, Fan HC, Lam SM. Int J Nurs Stud. 2010;47:1442-1450.
The combination of burnout and time pressures appeared to be associated with patient safety risks, according to this survey of Taiwanese nurses.