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- WebM&M Cases 1
- Perspectives on Safety 1
- Study 4
- Slideset 1
- Book/Report 8
- Newspaper/Magazine Article 3
- Special or Theme Issue 3
- Toolkit 1
- Web Resource 12
United States Meeting/Conference
- South Region Meeting/Conference 12
- United States Meeting/Conference 18
- Upcoming Meeting/Conference 28
- Press Release/Announcement 1
- Communication Improvement 4
- Culture of Safety 9
Education and Training
- Students 2
- Error Reporting and Analysis 7
- Human Factors Engineering 3
- Legal and Policy Approaches 4
- Quality Improvement Strategies 12
- Research Directions 1
- Specialization of Care 1
- Teamwork 3
- Technologic Approaches 5
- Transparency and Accountability 1
- Diagnostic Errors 5
- Failure to rescue 1
- Fatigue and Sleep Deprivation 1
- Interruptions and distractions 1
- Medical Complications 1
- Medication Safety 6
- Nonsurgical Procedural Complications 1
- Overtreatment 1
- Psychological and Social Complications 6
- Surgical Complications 3
- Family Members and Caregivers 1
- Health Care Executives and Administrators 60
Health Care Providers
- Nurses 1
Non-Health Care Professionals
- Educators 12
- Patients 4
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Cases & Commentaries
- Web M&M
Ken J. Farion, MD; July 2003
A physician in the ED mistakenly glues a child's eye shut when attempting to close a facial wound with skin adhesive.
Perspectives on Safety > Perspective
with commentary by Alison H. Page, MS, MHA, Just Culture, October 2007
We've all been there...something goes wrong, a patient is harmed, and we, as medical directors, managers, and administrators, are forced to judge the behavioral choices of another human being. Most of the time, we conduct this complex leadership function guided by little more than vague policies, personal beliefs, and intuition. Frequently, we are frustrated by the fact that many other providers have made the same mistake or behavioral choice, with no adverse outcome to the patient, and the behavior was overlooked. Quite understandably, the staff is frustrated by what appears to be inconsistent, irrational decision-making by leadership. The "just culture" concept teaches us to shift our attention from retrospective judgment of others, focused on the severity of the outcome, to real-time evaluation of behavioral choices in a rational and organized manner.
Audiovisual > Audiovisual Presentation
The Commonwealth Fund Quality Improvement Colloquium: Patient Safety Five Years After To Err Is Human.
Washington, DC: The National Academy of Sciences; November 4-5, 2004.
Experts participating in this event evaluated the progress made since the release of To Err is Human, and the steps needed to improve safety moving forward. This page includes archived video, transcripts, and presentation slides from the event as well as participant biographies.
Meeting/Conference > Government Resource
Workshop Brief, User Liaison Program. Rockville, MD: Agency for Healthcare Research and Quality; June 2-4, 2003.
The goals of this workshop included sharing new knowledge, tools, and strategies for states to use in improving their patient safety programs and policies. The Agency for Healthcare Research and Quality's (AHRQ) User Liaison Program (ULP) developed the workshop to disseminate health services research findings for practical use through interactive sessions.
Cook RI, Woods DD, Miller C. Chicago, IL: National Patient Safety Foundation; 1998.
A report from a workshop, this document is a well-written look at the differences between "first stories" and "second stories" describing major errors. First stories are the easy one-person or one-cause accounts and reactions to critical incidents. "So-and-so forgot to check the patient's allergy history." Or "How could they have ignored the alarm and so many other red flags?" Even now, with some penetration of the concepts of systems thinking, it is still easy to fall back on the familiar and easy explanation of human error, missing key opportunities to fix underlying problems with processes of care or the way care is organized. Identifying such problems, however, requires the far richer "second stories" about such critical incidents, and these stories do not emerge without hard work. The authors have done this hard work for many publicized medical errors, drawing on follow-up newspaper articles and other investigative documents, often in far more obscure places than headlining first stories. Even readers familiar with root cause analysis will likely find value in many of the case studies. And, for those not familiar with such accident investigation techniques, the report provides a very readable introduction to their importance and a resource for further references.
Journal Article > Study
Feinstein AR, Niebyl JR. Arch Intern Med. 1971;128:774-780.
This study reports and analyzes findings of traditional clinicopathologic conferences (CPC) from Massachusetts General Hospital. By comparing the distribution of topics and the accuracy in making correct diagnoses over several decades, the authors explore one of the oldest forms of reasoning. The cases reviewed were classified both by clinical topic and error type to better understand the trends and patterns seen in diagnostic failures. The authors discuss the teaching role employed by CPC and the potential for computers to play an integral role in the diagnostic reasoning process.
Journal Article > Study
Teaching medical students about medical errors and patient safety: evaluation of a required curriculum.
Halbach JL, Sullivan LL. Acad Med. 2005;80:600-606.
This study reports survey findings both before and after implementation of a new educational curriculum. The patient safety curriculum described targeted third-year medical students with a 4-hour session that included readings, interactive discussion, and videotaped standardized patient encounters. Findings suggested that the experience was useful and increased awareness about the topic area as desired. The authors discuss educational strategies, such as case-based teaching and patient safety conferences, which can foster greater and more consistent safety education for medical students throughout their training.
Patient safety and health information technology conference: A newsmaker interview with Carolyn M. Clancy, MD.
Barclay L. Medscape Medical News. June 10, 2005.
In this interview, Agency for Healthcare Research and Quality Director Carolyn M. Clancy talks about the role of health information technology in patient safety initiatives and shares strategies for successful implementation.
Journal Article > Study
Nonpunitive medication error reporting: 3-year findings from one hospital's primum non nocere initiative.
Potylycki MJ, Kimmel SR, Ritter M, et al. J Nurs Adm. 2006;36:370-376.
The investigators conducted a survey to inform the implementation of a nonpunitive medication error reporting policy and educational workshop. A comparison to post-initiative findings revealed that staff perception of reporting improved after the educational initiative.
Web Resource > Multi-use Website
Maryland Patient Safety Center.
This Web site includes information related to the Collaborative's efforts in supporting safety in hospital-based emergency care.
Journal Article > Commentary
Kravet SJ, Howell E, Wright SM. J Gen Intern Med. 2006;21:1192-1194.
The authors describe how they redesigned morbidity and mortality (M&M) conferences at their hospital to include a focus on systems failures and to address all six of the Accreditation Council for Graduate Medical Education (ACGME) core competencies.
Journal Article > Commentary
Development and evaluation of a 1-day interclerkship program for medical students on medical errors and patient safety.
Moskowitz E, Veloski JJ, Fields SK, Nash DB. Am J Med Qual. 2007;22:13-17.
Early education of students in the health professions is a recommended component of establishing a culture of safety. This study describes the effect of a patient safety seminar delivered to third-year medical students, which included lectures and workshop sessions. The students' attitudes and knowledge about patient safety issues improved as a result. Prior research has also found that brief curricula can increase patient safety awareness among medical students, but without reinforcement, this knowledge may deteriorate over time.
Tools/Toolkit > Toolkit
Building the Future for Patient Safety: Developing Consumer Champions—A Workshop and Resource Guide.
Chicago, IL: Consumers Advancing Patient Safety; 2007.
This guide describes the Consumers Advancing Patient Safety workshop process, which can be adapted and used to help consumers become active partners in patient safety work. Resources to be used during a workshop are also provided.
Journal Article > Study
A descriptive study of morbidity and mortality conferences and their conformity to medical incident analysis models: results of the morbidity and mortality conference improvement study, phase 1.
Aboumatar HJ, Blackledge CG Jr, Dickson C, Heitmiller E, Freischlag J, Pronovost PJ. Am J Med Qual. 2007;22:232-238.
Morbidity and mortality ("M&M") conferences are standard components of training programs and are mandated by the Accreditation Council for Graduate Medical Education. Despite their ubiquity, a prior study of internal medicine and surgery conferences found that errors were discussed infrequently (particularly in internal medicine); thus, housestaff were being denied an important patient safety learning opportunity. In this study, researchers interviewed conference leaders from 12 departments at an academic hospital and found that only a minority identified patient safety and quality improvement as an important learning objective for the conference. Conferences generally did not include recommended elements for analyzing and learning from errors (e.g., assigning responsibility for follow-up). A prior article described how one residency program redesigned M&M to focus on patient safety and learning from errors.
Hawkes N. BMJ. 2009;338:b2286.
This news article summarizes a conference that educated new physicians about medical errors and encouraged them to participate in safety improvement efforts.
Federico F, Bonacum D. Healthc Exec. January/February 2010;25:68-70.
This piece outlines steps such as training and senior leader support that can help enhance the role of middle managers in patient safety and quality improvement.
Special or Theme Issue
Andris DA, Mirtallo JM, Guenter P, eds. JPEN J Parenter Enteral Nutr. 2012;36(2 Suppl):1S-62S.
Articles in this special issue examine parenteral nutrition administration and provide tactics to improve the reliability of parenteral nutrition ordering, formulation, and delivery.
Meeting/Conference > Meeting/Conference Proceedings
Agency for Healthcare Research and Quality. September 9–12, 2012; Bethesda North Marriott Hotel & Conference Center, Bethesda, MD.
The Agency for Healthcare Research and Quality's 2012 conference, "Moving Ahead: Leveraging Knowledge and Action to Improve Health Care Quality," examined the status of health care and highlights AHRQ's work in striving to continue to move forward. Video of Dr. Carolyn Clancy's plenary session discussing the research community's role in efforts to transform the US health care system and session slides are available on the site.
Oakbrook Terrace, IL: Joint Commission; May 21–23, 2012.
Meeting/Conference > Florida Meeting/Conference
Institute for Safe Medication Practices. September 12–13, 2019, Maggiano's, Orlando, FL.