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- Perspectives on Safety 1
- Study 3
- Audiovisual 1
- Book/Report 9
- Legislation/Regulation 2
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- Grant 1
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- Error Reporting and Analysis 15
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- Specialization of Care 2
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- Medical Complications 8
- Medication Safety 7
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- Psychological and Social Complications 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.
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.
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.
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.
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.
Journal Article > Commentary
SQUIRE 2.0 (Standards for QUality Improvement Reporting Excellence): revised publication guidelines from a detailed consensus process.
Ogrinc G, Davies L, Goodman D, Batalden P, Davidoff F, Stevens D. BMJ Qual Saf. 2016;25:986-992.
The rapid growth in literature on patient safety and quality improvement (QI) has been accompanied by controversy about how such studies should be conducted and reported. Influential leaders have argued that QI studies demand a different standard of evaluation than traditional biomedical research, given their complexity. A contrary argument notes that failure to rigorously evaluate such research could result in wasted resources and unanticipated consequences if poorly evaluated interventions are widely implemented. Developed by expert consensus, these guidelines provide a blueprint for reporting the results of QI studies. Since its introduction in 2008, authors and journal editors have widely adopted these guidelines to standardize reporting of safety and QI studies. In 2015, the SQUIRE guidelines were revised through a process that included semistructured interviews, focus groups, consensus meetings, pilot testing with authors, and a public comment period. SQUIRE 2.0 improves the usability of the guidelines and omits the multiple sub-items that were felt to be too confusing for authors in the initial document.
Award > Award Recipient
Horsham, PA: Institute for Safe Medication Practices; November 7, 2008.
The Cheers awards annually recognize leaders in the field of medication safety. Among the 2008 honorees are FDA Patient Safety News; the Health Information Translations development consortium, Mount Carmel Health System, OhioHealth, The Ohio State University Medical Center, and Nationwide Children's Hospital; the Sebastian Ferrero Foundation; Debora Simmons, RN, MSN; and Diane Cousins, RPh.
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.
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.