Narrow Results Clear All
- Communication Improvement 3
- Education and Training 2
- Error Reporting and Analysis 4
- Human Factors Engineering 3
- Legal and Policy Approaches 3
- Logistical Approaches 2
- Quality Improvement Strategies 5
- Specialization of Care 1
- Clinical Information Systems 1
- Identification Errors 2
- Medical Complications 4
- Medication Safety 2
- Psychological and Social Complications 1
- Surgical Complications 3
- Transfusion Complications
Search results for ""
Cases & Commentaries
- Web M&M
Bryan A. Liang, MD, PhD, JD; May 2004
Understanding that she may lose her life without it, a woman severely injured in a collision rejects a blood transfusion for religious reasons. However, her parents persuade the physicians otherwise, and the woman lives.
Journal Article > Study
Changes in practice and organisation surrounding blood transfusion in NHS trusts in England 1995-2005.
Taylor CJC, Murphy MF, Lowe D, Pearson M. Qual Saf Health Care. 2008;17:239-243.
British hospitals have made significant progress in implementing safe blood transfusion practices, but not all hospitals have achieved high levels of performance.
More states shred bills for awful medical errors: patients in 23 states will no longer pay for certain mistakes, hospitals say.
Aleccia J. MSNBC News. August 12, 2008.
This article reports on the implementation and expansion of several states' non-payment policies for medical mistakes in light of similar policies set by Medicare and private insurance companies.
May H. Salt Lake Tribune. August 18, 2008.
This article examines 2007 state health data on never events in the context of a label-related medical error that resulted in a recent death.
Anderson HJ. Health Data Manag. January 1, 2009;17:18.
Although shifting from paper-based or verbal orders to computerized physician order entry (CPOE) systems could reduce medical errors, a mere 8% of hospitals use the system and fewer implement it effectively, according to the Leapfrog Group CPOE evaluation tool.
Golden, CO: HealthGrades, Inc.; April 2009.
This analysis of patient safety in Medicare patients from 2005–2007 concludes that while modest improvements have been made, patient safety incidents still account for nearly 100,000 preventable deaths and nearly $7 billion in excess costs yearly. The report also recognizes the best performing hospitals with a "Patient Safety Excellence Award"—hospitals scoring in the top 15% according to a ranking methodology developed by the authors. As with prior HealthGrades reports, the study uses the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSIs) to measure the incidence of patient safety problems and compare hospitals. The limitations of using PSIs as a performance measure have been discussed in a prior study and AHRQ WebM&M commentary, and it is important to note that this report did not undergo external peer review.
Oakbrook Terrace, IL: The Joint Commission; September 2012. ISBN: 9781599407555.
This e-book provides tips for incorporating activities into daily hospital practice in conjunction with the 2013 National Patient Safety Goals.
Journal Article > Study
Challenges and opportunities to prevent transfusion errors: a Qualitative Evaluation for Safer Transfusion (QUEST).
Heddle NM, Fung M, Hervig T, et al; BEST Collaborative. Transfusion. 2012;52:1687-1695.
This qualitative study evaluated the processes laboratories use to prevent transfusion of incompatible blood products, which is considered a never event.
Journal Article > Review
Bolton-Maggs PH, Cohen H. Br J Haematol. 2013;163:303-314.
This review summarizes results from a longstanding transfusion safety program in the United Kingdom and recommends strategies for improvement and error reduction based on that evidence.