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- Communication Improvement 1
- Culture of Safety 4
Education and Training
- Students 1
- Error Reporting and Analysis 8
- Human Factors Engineering 4
- Legal and Policy Approaches 3
- Policies and Operations 1
- Quality Improvement Strategies 4
- Teamwork 1
- Technologic Approaches 1
- Device-related Complications
- Discontinuities, Gaps, and Hand-Off Problems 2
- Medical Complications 7
- Medication Safety 4
- Surgical Complications 4
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Szabo L. USA Today. August 23, 2005.
This article reports the announcement of an international initiative to share patient safety strategies. The initiative will be led by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).
Berwick DM. Newsweek. December 12, 2005;46:75-78.
Institute for Healthcare Improvement President Don Berwick summarizes the six improvement measures of the 100K Lives Campaign.
Grant > Government Resource
Rockville, MD: Agency for Healthcare Research and Quality; June 2008.
This announcement describes the 19 projects funded by the Agency for Healthcare Research and Quality in 2006 that studies the potential of simulation to improve patient safety.
Landro L. Wall Street Journal. June 27, 2007:D3.
This article discusses errors associated with tubing misconnections in hospital-based care. A previous WebM&M commentary discussed a tubing error that led to administration of the wrong gas.
Tremlett G. Guardian.co.uk; July 13, 2009.
This newspaper article reports on a family that experienced two medical errors, resulting in the death of both a mother and her infant.
Consumer Reports. March 2010;75:16-21.
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.
Rojas-Burke J. The Oregonian. May 8, 2010.
This newspaper article describes how lessons from the Keystone ICU Project have reduced central line infections in Oregon hospitals.
Harris G. New York Times. August 21, 2010:A1.
This article describes documented look-alike issues with medical equipment that have yet to be addressed by federal regulation.
Harasim P. Las Vegas Review-Journal. November 21, 2010;News:1B.
This article discusses how the organizational system of one hospital delayed an investigation into catheter line malfunctions.
Moss-Coane M, O'Connell K, Fishman N. Radio Times. April 28, 2011.
This radio program featured interviews with an infectious disease specialist and a patient who contracted a hospital-acquired infection, and discussed how patients and providers can reduce their occurrence.
Woodall A. Oakland Tribune. September 27, 2011.
This newspaper article reports how a medical error, which occurred during a nursing strike, resulted in a patient's death.
Journal Article > Commentary
Minnier T, Phrampus P, Waddell L. JAMA. 2016;316:1207-1208.
Describing an incorrect procedure incident which involved placement of a dialysis catheter instead of a central line, this commentary outlines the root causes of the event and how it could have been prevented. A related editorial introduces Performance Improvement, a series of case-based articles intended to support frontline performance improvement efforts.
Kliff S, Pinkerton B, Weinberger J, Drozdowska A. Vox. October 23, 2017.