Narrow Results Clear All
- Patient Safety Primers 2
- WebM&M Cases 1
- Perspectives on Safety 2
- Commentary 17
- Review 10
- Study 38
- Audiovisual 3
- Book/Report 21
- Legislation/Regulation 2
- Newspaper/Magazine Article 12
- Special or Theme Issue 1
- Tools/Toolkit 1
- Web Resource 13
- Press Release/Announcement 3
- Communication Improvement 15
- Culture of Safety 6
- Education and Training 9
Error Reporting and Analysis
- Error Analysis 22
- Error Reporting
- Human Factors Engineering 10
Legal and Policy Approaches
- Regulation 14
- Logistical Approaches 2
- Policies and Operations 1
- Quality Improvement Strategies 21
- Specialization of Care 1
- Teamwork 2
- Technologic Approaches 11
- Transparency and Accountability 1
- Device-related Complications 2
- Diagnostic Errors 3
- Discontinuities, Gaps, and Hand-Off Problems 2
- Identification Errors 24
- Inpatient suicide 7
- Medical Complications 31
- Medication Errors/Preventable Adverse Drug Events 9
- Nonsurgical Procedural Complications 4
- Overtreatment 1
- Psychological and Social Complications 10
- Surgical Complications 45
- Transfusion Complications 5
- Dentistry 3
- Internal Medicine 35
- Nursing 3
- Pharmacy 3
- Family Members and Caregivers 1
- Health Care Executives and Administrators 88
Health Care Providers
- Nurses 2
- Physicians 10
- Non-Health Care Professionals 39
- Patients 14
- Australia and New Zealand 6
- Europe 11
- Canada 6
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Cases & Commentaries
- Web M&M
Michael J. Barrington, MBBS, PhD, and Yoshiaki Uda, MBBS; April 2017
An older woman admitted to the medical-surgical ward with multiple right-sided rib fractures received a paravertebral block to control the pain. After the procedure, the anesthesiologist realized that the block had been placed on the wrong side. The patient required an additional paravertebral block on the correct side, which increased her risk of complications and exposed her to additional medication.
Perspectives on Safety > Interview
Organizations Working to Improve Quality and Safety, June 2015
Dr. Cassel, President and CEO of the National Quality Forum (NQF), is a leading expert in geriatric medicine, medical ethics, and quality of care. We spoke with her about NQF's work in developing and utilizing quality measures to improve safety in health care.
Perspectives on Safety > Annual Perspective
with commentary by Sumant Ranji, MD, 2016
The toll of medical errors is often expressed in terms of mortality attributable to patient safety problems. In 2016, there was considerable debate regarding the number of patients who die due to medical errors. This Annual Perspective explores the methodological approaches to estimating mortality attributable to preventable adverse events and discusses the benefits and limitations of existing approaches.
Patient Safety Primers
The list of never events has expanded over time to include adverse events that are unambiguous, serious, and usually preventable. While most are rare, when never events occur, they are devastating to patients and indicate serious underlying organizational safety problems.
Patient Safety Primers
Falls are a common source of patient harm in hospitals, and are considered a never event when they result in serious injury. Fall prevention requires a coordinated, multidisciplinary approach that entails individualized risk assessment and preventive interventions.
Journal Article > Commentary
West JC. J Healthc Risk Manag. 2006;26:15-21.
The author compares surgical event data from the first Minnesota state report on medical error with published research on similar incidents. He concludes that, because adverse events occur infrequently in individual institutions, large-scale databases are needed to aggregate data for study.
Baltimore, MD: Centers for Medicare & Medicaid Services (CMS) Office of Public Affairs; May 18, 2006.
This fact sheet provides information regarding the Centers for Medicare and Medicaid Services' initiative to better understand and minimize never events.
St. Paul, MN: Minnesota Department of Health; March 2019.
The National Quality Forum has defined 29 never events—patient safety problems that should never occur, such as wrong-site surgery and patient falls. Since 2003, Minnesota hospitals have been required to report such incidents. The 2018 report summarizes information about 384 adverse events that were reported and found pressure ulcers and invasive procedure events increased, while fall-related deaths decreased. Reports from previous years are also available.
St. Paul, MN: Minnesota Department of Health; January 2009.
This report provides background on the Minnesota Never Events reporting initiative, tips for patients on how to receive the safest care possible, and a table of events reported by all hospitals in the state.
Blaney B. Associated Press [USA Today]. March 12, 2007.
This article reports on the abduction of a newborn by an individual masquerading as a hospital employee. Infant abduction is one of the patient safety "never events" defined by the National Quality Forum.
Journal Article > Review
Achieving the National Quality Forum's "Never Events": prevention of wrong site, wrong procedure, and wrong patient operations.
Michaels RK, Makary MA, Dahab Y, et al. Ann Surg. 2007;245:526-532.
Wrong site operations are rare and often occur when systems to prevent them fail. This study reviewed existing prevention strategies, such as the Joint Commission's Universal Protocol, to develop a framework for hospitals to assess their wrong site event prevention efforts. The proposed framework asks whether a behaviorally specific policy has been enacted and whether staff understand the policy, and goes on to recommend directly observing the policy being put into practice. The authors advocate standardized interventions utilizing effective methods to measure safety. A previous Agency for Healthcare Research and Quality (AHRQ) WebM&M commentary discusses factors that place patients at risk for wrong site surgery.
Washington, DC: National Quality Forum; 2011. ISBN: 9780982842188.
The National Quality Forum originally defined 27 health care "never events"—patient safety events that pose serious harm to patients, but should be considered preventable—in 2002. The 2011 update now consists of 29 events, organized into surgical events (e.g., wrong-site surgery), device events (e.g., air embolism), care management events (e.g., death or disability due to medication errors), patient protection events (e.g., patient suicide), environmental events (e.g., fires), radiologic events, and criminal events. One notable addition to the original list is that serious harm associated with failure to properly follow up on test results is now considered a never event. Since the development and dissemination of this list, many states have mandated that health care facilities report all instances of these events. When such an event occurs, many institutions mandate performance of a root cause analysis.
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.
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.
Carpenter D. Hosp Health Netw. November 2007;81:34-38.
O'Reilly KB. American Medical News. January 7, 2008.
This article discusses the evolving payer trend to withhold hospital reimbursement related to never events.
Journal Article > Commentary
Vastag B. JAMA. 2001;285:869-871.
This interview with Dr. Kizer, then of the National Quality Forum, addresses the inception of now well-known quality improvement strategies including compiling evidence-based safe practices and preventing "never events."
Ostrom CM. Seattle Times. January 29, 2008;News section:A1.
This article discusses a voluntary initiative in the state of Washington to cease billing patients for costs associated with preventable errors.
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
Mills PD, DeRosier JM, Ballot BA, Shepherd M, Bagian JP. Jt Comm J Qual Patient Saf. 2008;34:482-488.
The Department of Veterans Affairs has pioneered the use of root cause analysis to identify systems causes of adverse events. This study reports on the use of this technique to analyze inpatient suicide attempts at VA hospitals. Suicide attempts, the majority of which occur on inpatient psychiatric units, are considered a health care never event. Review of root cause analysis reports over a 7-year period identified several methods of self-harm and factors that facilitated suicide attempts. A prior study reported on preventive mechanisms that have been implemented at VA hospitals to reduce the risk of inpatient suicide attempts.