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- WebM&M Cases 2
- Perspectives on Safety 1
- Review 2
- Study 10
- Slideset 1
- Book/Report 32
- Legislation/Regulation 1
- Newspaper/Magazine Article 120
- Toolkit 3
- Web Resource 25
- Press Release/Announcement 1
- Communication Improvement 43
- Culture of Safety 13
- Education and Training 31
Error Reporting and Analysis
- Error Reporting 50
- Human Factors Engineering 23
Legal and Policy Approaches
- Regulation 10
- Logistical Approaches 14
- Policies and Operations 2
Quality Improvement Strategies
- Benchmarking 11
- Specialization of Care 8
- Teamwork 3
- Clinical Information Systems 7
- Transparency and Accountability 7
- Device-related Complications 14
- Diagnostic Errors 23
- Discontinuities, Gaps, and Hand-Off Problems 17
- Drug shortages 1
- Failure to rescue 1
- Fatigue and Sleep Deprivation 4
- Identification Errors 5
- Interruptions and distractions 1
- Medical Complications 58
- Medication Errors/Preventable Adverse Drug Events 12
- Nonsurgical Procedural Complications 3
- Psychological and Social Complications 11
- Surgical Complications 30
- Transfusion Complications 3
- Allied Health Services 1
- Internal Medicine
- Nursing 5
- Palliative Care 2
- Pharmacy 3
- Family Members and Caregivers 22
- Health Care Executives and Administrators 54
Health Care Providers
- Nurses 3
- Physicians 15
Non-Health Care Professionals
- Media 6
- Australia and New Zealand 1
- Europe 19
- Canada 6
- United States of America 169
Search results for ""
Cases & Commentaries
- Spotlight Case
- Web M&M
Elizabeth B. Lamont, MD, MS; September 2004
Following hernia repair surgery, an elderly woman is incidentally found to have a mass in her neck. Expecting the worst, the treating physician recommends palliative care and withdrawal of mechanical ventilation, before biopsy results are in.
Cases & Commentaries
- Web M&M
Russ Cucina, MD, MS; July 2006
Despite full documentation and a wristband regarding her severe food allergy, an inpatient is advertently fed eggs and suffers an allergic reaction.
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...
Washington, DC: Leapfrog Group.
This website offers resources related to the Leapfrog Hospital Survey investigating hospitals' progress in implementing specific patient safety practices. Updates to the survey include increased time allotted to complete computerized provider order entry evaluation, staffing of critical care physicians on intensive care units, and use of tools to measure safety culture. Reports discussing the results are segmented into specific areas of focus such as health care-associated infections and medication errors.
Tools/Toolkit > Fact Sheet/FAQs
Chicago, IL: National Patient Safety Foundation.
Postoperative infections represent a common and often preventable event. This patient fact sheet outlines practical tips to minimize risk.
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.
Journal Article > Commentary
Medication errors in family practice, in hospitals and after discharge from the hospital: an ethical analysis.
Clark PA. J Law Med Ethics. 2004;32:349-357.
In this article, the author urges the medical community to universally apply the systems approach to safety toward the reduction of medical errors. The author calls for health care to take medication errors more seriously and for patients to help drive improvement.
Grady D. New York Times. April 30, 2005.
The author reports on incidents in an Angolan hospital where doctors and patients were exposed to a deadly virus when hospital staff violated infection control procedures.
Saving lives: hospitals have signed on to a six-part plan to avoid a multitude of unnecessary deaths.
Comarow A. US News & World Report. July 18, 2005;139:74,76,79.
This article, accompanying the widely read ranking of "America's Best Hospitals," describes the Institute for Healthcare Improvement's 100,000 Lives Campaign. Focusing on the six practices promoted by the campaign, it reviews the progress to date, with a particular focus on two participating hospitals' (Hackensack University Medical Center in New Jersey and McLeod Regional Medical Center in South Carolina) experiences in implementing the practices.
Kowalczyk L. The Boston Globe. December 22, 2005.
This article reports on several hospitals in Massachusetts that continue to perform obesity surgeries, despite falling short of the recommended number of operations per year to meet voluntary patient safety guidelines.
Kapadia R. Smart Money. October 2006;15:112-114.
This article provides tips for consumers to help keep their hospital care as safe and hassle-free as possible.
Berwick DM, Leape LL. Newsweek. October 16, 2006:70-71.
As part of the "Health for Life" series, Drs. Berwick and Leape discuss the notion of completely eliminating medical errors and share stories about several hospitals' efforts to raise safety standards.
Davis R. USA Today. October 25, 2006.
This article shares stories of missed heart attack diagnoses and is accompanied by an online poll for readers to share their experiences with medical error.
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.
Zimmerman R. Wall Street Journal. February 6, 2007:A1.
This article reports on a mother's campaign to educate parents about kernicterus and to make bilirubin tests standard for all newborns.
Lerner BH. The Washington Post. November 28, 2006:HE01.
The author reviews the legacy of Libby Zion and how her untimely death raised awareness of the impact that resident duty hours and fatigue could have on patient care and quality.
Breast Cancer Services in Trafford and North Manchester. An Investigation Into The Circumstances Surrounding A Serious Clinical Incident In Symptomatic Breast Services – The Baker Report.
Baker M. Manchester, England: NHS North West; February 2007.
This report shares findings from an investigation into individual and system failures that contributed to a radiologist misreading mammograms for a 2-year period.
Victoria Times Colonist. March 26, 2007.
This article reports on findings from an investigation into hospital-acquired infections in British Columbia.
Golden, CO: HealthGrades, Inc.; April 2007.
This fourth annual report on the safety of hospitalized Medicare patients builds on past efforts to evaluate hospital performance. The report uses the Agency for Healthcare Research and Quality's Patient Safety Indicators to provide benchmarks for such performance, identify current trends in safety issues, and estimate preventable events nationally. The report suggests that the patient safety incidents captured account for nearly $9 billion in excess cost during 2003-2005, and nearly 250,000 potentially preventable deaths occurred during the same time period. Grading for all states and a selected group of highly rated hospitals is included with the implication that, if all hospitals performed at a level comparable to the ones acknowledged, more than 34,000 Medicare deaths could be avoided with a cost savings of $1.74 million. As with the second and third annual reports, several methodological limitations exist, and the reports themselves did not receive external peer review.
Landro L. Wall Street Journal. July 11, 2007:D1.
This article reports on hospitals that are creating dedicated teams of experts who have the skills to perform risky medical procedures.