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- Commentary 271
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- Special or Theme Issue 19
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Communication between Providers
- Sbar 3
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- Simulators 19
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- Error Analysis
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Human Factors Engineering
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Legal and Policy Approaches
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- Identification Errors 25
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- Medical Complications 92
- Medication Errors/Preventable Adverse Drug Events 253
- MRI safety 4
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Health Care Executives and Administrators
- Risk Managers 209
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United States of America
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Search results for ""
Tools/Toolkit > Measurement Tool/Indicator
AHRQ Quality Indicators. Rockville, MD: Agency for Healthcare Research and Quality; September 2005.
The Agency for Healthcare Research and Quality's (AHRQ) Quality Indicators (QIs) represent quality measures that make use of a hospital's available administrative data. The Inpatient Quality Indicators include inpatient mortality for certain procedures and medical conditions; utilization of procedures for which there are questions of underuse, overuse, and misuse; and volume of procedures for which evidence suggests that a higher volume is associated with lower mortality.
Journal Article > Study
Cooper JB, Newbower RS, Long CD, McPeek B. Anesthesiology. 1978;49:399-406.
This study reports on the retrospective analysis of nearly 360 preventable incidents at an urban teaching institution and was a first in using human factors research methods in an anesthesia setting. To determine patterns of failure in anesthetic practice, the investigators conducted interviews with staff and anesthesiologists before performing a critical-incident analysis. This methodology aims to translate anecdotal experiences into systematic study of human performance. Findings attributed the majority of incidents to human error, with a relatively small percentage due to pure equipment failure. The authors suggest that their method of examining incidents may be effective to help pool similar data from other institutions and design system strategies for prevention.
Journal Article > Commentary
Pierce EC. Anesthesiology. 1996;29:965-975.
In this article based on a special lecture delivered at the 1995 annual meeting of the American Society of Anesthesiologists (ASA), the author provides an historical perspective on the birth of patient safety in the field of anesthesia. From personal anecdotes in the operating room to descriptions of emerging research around postoperative deaths, the presentation provides a unique perspective on the gradual emergence of safety efforts in anesthesia. In addition, Pierce discusses the factors that led him to develop the first ASA Committee on Patient Safety and Risk Management, host the first International Symposium on Preventable Anesthesia Mortality and Morbidity, and form the Anesthesia Patient Safety Foundation. Pierce closes by introducing the challenges that lie ahead in balancing the commitment to safety with the growing climate of cost-containment and productivity.
Legislation/Regulation > Organizational Policy/Guidelines
Washington, DC: Veterans Health Administration; March 4, 2011.
A handbook developed by the VA and the National Center for Patient Safety that provides guidance on how to limit opportunities that adversely impact patient safety and care. The strategies discussed incorporate the use of root cause analysis, a tool designed to understand and communicate safety-related issues.
Tools/Toolkit > Government Resource
VA National Center for Patient Safety.
These materials provide an introduction to the purpose of healthcare failure mode and effect analysis (HFMEA), the steps of the HFMEA process, and how to apply the technique to address the Joint Commission proactive risk assessment standard.
Journal Article > Review
A review of the literature examining linkages between organizational factors, medical errors, and patient safety.
Hoff T, Jameson L, Hannan E, Flink E. Med Care Res Rev. 2004;61:3-37.
An exploration of the role that organizational factors play in achieving patient safety improvement. The authors conclude that little evidence exists to support the impact an individual or organizational component has on minimizing error. Improvements needed to increase the effectiveness of future research are reviewed.
Corbett C, Clapper C, Johnson KM, Sheff RA. Marblehead, Mass: HCPro, Inc.; 2004.
A "how-to" book for organizations that have already implemented a root cause analysis (RCA) process in response to JCAHO's standards. The book provides opportunities to improve current processes and procedures.
Journal Article > Commentary
Wieman TJ, Wieman EA. J Surg Oncol. 2004;88:115-121.
The authors examine medical error reduction from a fundamental systems point of view by using variables such as human and system behavior.
Journal Article > Commentary
Berwick DM. Ann Intern Med. 2005;142:121-125.
Dr. Donald Berwick writes this compelling piece as a personal reflection on the current deficiencies in healthcare quality. As he prepares for a knee replacement, he defines five dimensions of total quality that he believes every patient deserves when receiving care at a healthcare institution. The dimensions are no needless deaths, no needless pain, no helplessness, no unwanted waiting, and no waste. The author discusses each of these dimensions and shares numerous anecdotes and analogies to vividly illustrate his points. He fears that no institution can meet his criteria today but points to the future of change that is required.
Special or Theme Issue
Fein AM, Heffner JE, eds. Crit Care Clin. January 2005;21(theme issue):1-175.
Recognizing the complexity of the critical care environment, the editors provide access to expert thought in this special issue. Topics covered include the use of failure mode and effects analysis, organizational and cultural strategies, and medication error in critical care.
Journal Article > Study
Pierluissi E, Fischer MA, Campbell AR, Landefeld CS. JAMA. 2003;290:2838-2842.
Traditional morbidity and mortality conferences were designed to focus on educational opportunities to learn from an error or adverse event. This study examined how frequently such conferences actually fulfilled their mission by observing more than 330 of them in both internal medicine and surgery. Investigators discovered that internal medicine conferences involved more lengthy case presentations and discussions, more time listening to invited speakers, and less time in audience discussion. Surgery conferences more frequently presented errors and adverse events and also attributed errors to a particular cause. The authors discuss the lost opportunity for learning and the potential for closing such gaps with improved conference facilitation and an emphasis on using specific language and modeling directed towards system improvement. AHRQ WebM&M offers an online version of such a conference with presentation of cases and expert commentaries discussing relevant safety issues.
Journal Article > Study
Thomas EJ, Petersen LA. J Gen Intern Med. 2003;18:61-67.
This article discusses the strengths and weaknesses of eight different strategies to measure errors and adverse events. The methods discussed include incident reporting systems, autopsies and morbidity and mortality conferences, malpractice claims, chart review, administrative data analysis, information technology, direct observation, and clinical surveillance. The authors further categorize these measurement strategies based on their relative utility in detecting latent versus active errors as well as adverse events. They also explain how the different methods fit into previously presented and contrasting paradigms (by Leape et al and Shojania et al) for error measurement, patient safety, and evidence-based medicine. This article provides a review and argument for a comprehensive multidimensional approach to measuring errors.
Tools/Toolkit > Toolkit
Pathways for Medication Safety Tool #2. Chicago, IL: American Hospital Association; 2003.
A compendium of risk assessment tools to assist in the prevention of medication errors. The tools emphasize the importance of a multidisciplinary approach to managing risk with key sections focusing on physicians, nurses, pharmacists, risk managers, and administrators.
Legislation/Regulation > Multi-use Website
The Joint Commission.
Since 1998, The Joint Commission has issued sentinel event alerts in response to unexpected incidents involving death or serious physical or psychological injury (or risk thereof). These events are identified as sentinel due to the gravity of the injury and the need for immediate investigation and response. The goal is often to determine the root causes involved and provide recommendations for future prevention. The Sentinel Event Alert Web site includes a complete library of previous sentinel event alerts, along with related statistics, podcasts, forms, tools, policy and procedures, and a frequently asked questions section reviewing selected recent topics.
Legislation/Regulation > Sentinel Event Alerts
The Joint Commission. Sentinel Event Alert. December 20, 2004;(33):1-2.
Patient-controlled analgesia (PCA) is a recognized method of controlling pain when administered by credentialed practitioners. However, serious adverse events can result when unauthorized family members, caregivers, or clinicians administer the analgesia for the patient "by proxy." The Joint Commission summarizes the experience of reported PCA incidents and makes recommendations to minimize them.
Tools/Toolkit > Multi-use Website
The VA Getting at Patient Safety (GAPS) Center.
Stories from a variety of disciplines are provided to illustrate fundamental patient safety concepts. This site presents a narrative with visual and text-based aids, presentation slides, a human factors explanation of the concept, discussion questions, and links to additional resources.
Audiovisual > Audiovisual Presentation
Schiff G. "Eight Forty-Eight." Chicago Public Radio. October 16, 2004.
Quality and honesty play an influential role in the safety and cost of medical care. Gordon Schiff, the director of clinical and quality research (Department of Medicine at Stoger Hospital, Chicago, Illinois), explains how research findings helped uncover the hidden costs associated with making and then hiding medical error. The interview runs 13 minutes.
Tools/Toolkit > Toolkit
Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations.
This worksheet outlines elements of Failure Mode, Effect, and Criticality Analysis (FMECA), such as writing down process points, potential failure modes, and their potential effect.
Woods DD, Cook RI. In: Youngberg BJ, Hatlie MJ, eds. The Patient Safety Handbook. Sudbury, MA: Jones and Bartlett; 2004:95-108.
This chapter discusses the "New Look" as a paradigm shift in understanding the complexity of error and how to seek solutions to mitigate it. The difficulty in identifying "error" is framed in the work of Rasmussen and Hollnagel.
Chicago, IL: American Society of Healthcare Risk Management; 2002.
The implementation and application of proactive risk assessment is reviewed. In that context, the authors discuss evidentiary protection and discoverability of information. Risk managers provide pearls from their experience, applying failure mode and effects analysis (FMEA).