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- Communication Improvement 3
- Culture of Safety 1
- Education and Training 2
- Error Reporting and Analysis 11
- Human Factors Engineering 1
- Legal and Policy Approaches
- Quality Improvement Strategies 5
- Technologic Approaches 3
- Transparency and Accountability 4
- Device-related Complications 1
- Identification Errors 1
- Medical Complications 1
- Medication Errors/Preventable Adverse Drug Events 3
- Nonsurgical Procedural Complications 1
- Surgical Complications 1
Search results for ""
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.
San Francisco, CA: The Leapfrog Group; May 2, 2006.
This news release announces that 22 California hospitals have been recognized for their achievements in addressing The Leapfrog Group's standards of quality and safety.
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.
Legislation/Regulation > New Jersey Legislation
New Jersey Legislature. A4327 (2007).
This bill amends a previous law by requiring that serious preventable adverse events be reported to the New Jersey Department of Health and Senior Services and that a list of these errors and where they occurred be publicly available.
Collins LM. Deseret Morning News. July 8, 2007;A1.
This article reports on Utah health officials' recent efforts to mandate error reporting, make that information open to the public, and use the data to improve patient safety.
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.
Rusk K. Assignment 7. ABC7news.com. May 26, 2008.
In the context of statewide efforts to prevent medication errors, increase reporting, and share best practices, this news video addresses how hospitals are employing both low- and high-tech solutions to improve patient safety. The story also covers barcoding, the Five Rights, transparency, and efforts to get safety information into patients' hands.
Smith S. Boston Globe. July 30, 2008;Metro section:1A.
This article reports on the incidence of wrong site surgeries in Massachusetts and describes complex factors that may contribute to such errors occurring in spinal surgery.
Greene L. St. Petersburg Times. August 19, 2008.
This article reports on recent apologies made by Florida hospital officials for medical errors.
Kauffman M, Altimari D. The Hartford Courant. November 15, 2009;Final:A1.
This newspaper article reports that a Connecticut law intended to make hospital errors more transparent has had the opposite effect by making it easier for hospitals to limit publicly available information on adverse events.
Allen M, Richards A. Las Vegas Sun. June 27, 2010.
This news series reports on an investigation that included hospital record review and interviews with stakeholders to explore the quality and safety of health care in Las Vegas.
Grant M. AARP The Magazine. September/October 2010;53:48-51,90-91.
Bogdanich W, Rebelo K. New York Times. December 28, 2010;A1.
This article explores inaccuracy of dosage, lack of protocol adherence, and absence of transparency as trends that hinder learning from radiological adverse events.
Web Resource > Multi-use Website
This organization rates online health care report cards and provides tips for reporting quality concerns.
Allen M. Washington Monthly. March/April 2011.
This magazine article reports on medical errors in the United States health care system and discusses transparency as a tactic to improve patient safety.
Eisler P, Hansen B. USA Today. August 20, 2013.
This newspaper article reports on physicians with records of misconduct and how poor oversight for monitoring and discipline allows them to continue practicing medicine.
Stock S, Putnam J, Carroll J, Pham S. NBC Bay Area. November 19, 2014.
Hospital reporting of errors in the United States has been suboptimal. This news video investigates the effectiveness of a state reporting initiative in California. Although hospitals have reported 6282 adverse events to the state in 4 years, patient safety experts suggest that those results do not reliably represent all the incidents that should have been submitted.
Rau J. Washington Post. May 17, 2016.
Collecting data to meet quality measurement requirements adds to resource burden for many health care organizations, and there is controversy around the benefits of such rating systems for both patients and clinicians. This news article discusses problems with the Centers for Medicare and Medicaid Services rating mechanism, Hospital Compare.
Rau J. National Public Radio. July 27, 2016.
Although quality rating systems have yet to receive approval across the health care industry, they still serve as a way for consumers to select hospitals and providers. The developers of rating services continue to refine metrics to hone their effectiveness. This news article reports on the latest set of ratings from the Hospital Compare program and concerns associated with the results.
Ornstein C. Health Shots. National Public Radio and ProPublica. April 18, 2017.
Summary data about serious errors in hospitals are available, but often details of accreditation investigation findings are not accessible to the public. This news article reports on efforts by the Centers for Medicare and Medicaid Services to make this information publicly available to augment transparency and enhance health care safety.