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- Perspectives on Safety 1
- Study 1
- Audiovisual 1
- Book/Report 4
- Legislation/Regulation 1
- Newspaper/Magazine Article 8
- Web Resource 6
- Award 1
- Press Release/Announcement 1
- Communication Improvement 2
- Culture of Safety 6
- Education and Training 1
- Error Reporting and Analysis 10
- Human Factors Engineering 3
- Legal and Policy Approaches 7
- Quality Improvement Strategies 7
- Device-related Complications 2
- Discontinuities, Gaps, and Hand-Off Problems 1
- Medical Complications 4
- Medication Safety 5
- Nonsurgical Procedural Complications 1
- Surgical Complications 3
- Health Care Executives and Administrators 15
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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.
Hospital-error oversight called lax: state takes too long to investigate mistakes, patient advocates say.
Galloway A. Seattle Post-Intelligencer. May 5, 2005.
This article explores inefficiencies in the process for reporting and investigating adverse events in Washington and indicates that inconsistent error review is a problem across the nation.
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.
USA Today. July 4, 2005.
This editorial supports legislation such as the Fair and Reliable Medical Justice Act, which calls for special courts to evaluate medical malpractice cases.
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.
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 > 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.
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.
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.
Dr Foster Intelligence Unit. London, UK: Imperial College London; 2009.
This consumer-focused report ranked the 148 hospital trusts in the United Kingdom National Health Service (NHS) on patient safety, clinical effectiveness, and patient experiences and found wide variation in the scores.
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.
Rau J. Kaiser Health News. October 17, 2011.
The Centers for Medicare & Medicaid Services (CMS) published data on hospital-acquired conditions in a 2011 report. This news article discusses new data available on the Hospital Compare Web site, including preventable complications and certain types of medical errors.
Web Resource > Government Resource
Division of Licensing and Regulatory Services, Maine Department of Health and Human Services.
This Web site provides information about Maine's statewide incident reporting initiative and includes annual sentinel event reports.
Clark C. HealthLeaders Media. September 13, 2013.
This news piece highlights concern around the safety of elective premature deliveries and describes techniques organizations have used to prevent such procedures.
Web Resource > Database/Directory
Columbia, SC: Mothers Against Medical Error; 2010.
This directory provides a listing of organizations and individuals dedicated to safe provision of health care.
Oakbrook, IL: Joint Commission; March 4, 2015.
The Eisenberg Award honors individuals and organizations who have made vital accomplishments in improving patient safety and quality. The 2014 honorees are Mark L. Graber, MD, the American College of Surgeons National Surgical Quality Improvement Program, and North Shore-LIJ Health System in New York. The awards were presented at the National Quality Forum's annual conference on March 23, 2015, in Washington, DC.