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Rosenthal J, Booth M. Portland, ME: National Academy for State Health Policy; November 2004.
Six states have enacted legislation to support the development of state patient safety centers to address the problem of medical errors. This report examines the various models applied in these states to design, administer, and monitor the centers.
Legislation/Regulation > Legislation/Case Law
Enacting the Washington state patient safety act requiring hospital staffing plans for nursing services and establishing recordkeeping and reporting requirements.
Washington State Legislature. HB 1602 (2003).
This addition to the Washington Patient Safety Act requires hospitals to develop and implement a staffing plan for nursing services. The plan addresses personnel issues for each patient care unit, requires hospitals to maintain records regarding patients and nursing care personnel, and authorizes the Department of Health to investigate complaints of staffing plan requirement violations and to conduct audits.
Legislation/Regulation > Congressional Testimony
Hearings before the House Insurance Committee of the Pennsylvania General Assembly. (April 22, 2004) (statement of James R. Combes, MD, senior medical advisor, HAP).
This statement introduces the Pennsylvania Patient Safety Reporting System (PA-PSRS), a statewide reporting initiative.
Tools/Toolkit > Toolkit
This four-chapter report defines "health literacy" and provides strategies for states to address existing educational gaps. It outlines the existing activities of interested stakeholders and summarizes the findings of a survey conducted by the Council on State governments. The report ultimately offers supportive tools for state policy makers to clarify relevant issues in their own states.
Web Resource > Multi-use Website
333 Market Street, Lobby Level, Harrisburg, PA 17120.
The Patient Safety Authority is an independent state agency charged with taking steps to reduce and eliminate medical errors by identifying problems and recommending solutions. The site includes information on the mandatory statewide Pennsylvania Patient Safety Reporting System.
Web Resource > Multi-use Website
University of Michigan Health System, 1500 E. Medical Center Dr., Ann Arbor, MI 48109. Phone: (734) 936-4000.
The University of Michigan's Patient Safety Enhancement Program (PSEP) aims to improve the quality of patient care by conducting research that focuses on methods to prevent adverse patient outcomes.
Web Resource > Multi-use Website
University of California Medical Centers.
The Strategic Alliance For Error Reduction in California Healthcare (SAFER) was organized by the Medical Directors of the University of California system in 1999. The Directors recognized that quality improvement was universally agreed on as being a serious and common concern of all five campuses, and they built SAFER to serve as the infrastructure through which to coordinate and share previously independent patient safety efforts.
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 > Pennsylvania Legislation
The General Assembly of Pennsylvania. HB957 (2005).
This bill calls for a prohibition of mandatory overtime and limiting the work week to 12 hours a day or 60 hours a week for non-supervisory health care employees in Pennsylvania. It is presently under consideration by Pennsylvania's General Assembly.
Ebright PR, Rapala K. Indianapolis, IN: Center for Urban Policy and the Environment; September 2005:1-7.
This brief report discusses important issues for policy makers in developing a statewide incident reporting system.
Tools/Toolkit > Multi-use Website
Portland, ME: National Academy for State Health Policy.
This online toolkit provides sample documents, policies, and Web site links related to the 27 states that have implemented adverse event reporting initiatives.
Postman D. The Seattle Times. February 21, 2006:A1.
This article reports on a compromise reached by doctors and lawyers in Washington state. The proposed bill would allow physicians to apologize for mistakes without the apology being used against them in court.
PA-PSRS Patient Saf Advis. March 2006;3:13-19.
This article addresses strategies for minimizing patient safety risks related to interactions with health care industry representatives, as well as the role they can play in promoting safety.
Web Resource > Government Resource
New Jersey Department of Health and Senior Services.
This Web site supports the data collection and educational initiatives associated with New Jersey's incident reporting program. The site includes reporting forms, instructions, and a patient safety newsletter.
Harrisburg, PA: Patient Safety Authority. ISSN 1941-7144.
This quarterly newsletter shares insights and analysis on incident reports submitted through the Pennsylvania Patient Safety Reporting System.
Evanston, IL: Office of the Governor; July 13, 2006.
This news release announces the governor's plans to improve patient safety in Illinois, including the use of e-prescribing by all providers and a Division of Patient Safety within the state public health department.
Journal Article > Study
Performance of International Classification of Diseases, 9th Revision, Clinical Modification codes as an adverse drug event surveillance system.
Hougland P, Xu W, Pickard S, Masheter C, Williams SD. Med Care. 2006;44:629-636.
This Agency for Healthcare Research and Quality (AHRQ)–supported study evaluated the effectiveness of using designated ICD-9 codes to detect adverse drug events (ADEs). Investigators convened an expert panel to identify codes representing ADEs and then performed retrospective chart reviews with a structured tool to determine the success of this methodology. Overall, flagged ADE codes detected just more than half of ADEs causing hospital admission, making it a readily available tool but not a comprehensive one. Past studies have evaluated the use of ICD-9 codes for similar purposes and for surveillance of device-related hazards.
Award > Award Recipient
Rabinowitz ABK, Clarke JR, Marella W, et al. Jt Comm J Qual Patient Saf. 2006;32:676-681.
Harrisburg, PA: Pennsylvania Health Care Cost Containment Council; November 2006.
This report includes findings on the number and rate of infections in Pennsylvania hospitals in 2005.
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.