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- Perspectives on Safety 4
- Review 1
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Search results for ""
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...
Perspectives on Safety > Perspective
with commentary by Rosemary Gibson, MSc, The Patient's Role in Safety, March 2007
Patients have three roles in improving patient safety: helping to ensure their own safety, working with health care organizations to improve safety at the organization and unit level, and advocating as citizens for public reporting and accountability of hospital and health system performance. The following case illustrates how patients can help ensure their own safety.
Perspectives on Safety > Interview
The Patient's Role in Safety, March 2007
Sorrel King is the mother of Josie King, who died tragically in 2001 at age 18 months because of medical errors during a hospitalization at Johns Hopkins Hospital. She has subsequently become one of the nation’s foremost patient advocates for safety, forming an influential foundation (the Josie King Foundation) and partnering with Johns Hopkins to promote the field of patient safety around the world.
Perspectives on Safety > Annual Perspective
with commentary by Rachel J. Stern, MD, and Urmimala Sarkar, MD, 2017
Patient engagement in safety has evolved from obscurity to maturity over the past two decades. This Annual Perspective highlights emerging approaches to engaging patients and caregivers in safety efforts, including novel technological innovations, and summarizes the existing evidence on the efficacy of such approaches.
Gawande A. The New Yorker. December 6, 2004;82-91.
A sensitive portrayal of the challenges in defining quality and implementing change even when practitioners are committed to high-quality care.
van Vuuren W. [dissertation]. Eindhoven, The Netherlands: Eindhoven University of Technology; 1998.
This report provides a detailed review of risk management in complex and high-risk organizations. The author focuses on the analysis and categorization of safety-related incidents and their organizational causes.
Web Resource > Multi-use Website
AORN, Inc., 2170 South Parker Rd, Suite 300, Denver, CO 80231-5711.
This site hosts a guideline collection as a part of the Association of PeriOperative Registered Nurses' (AORN) patient safety initiative targeting the needs of perioperative registered nurses. It develops new guidelines related to patient safety issues (such as medication safety and prevention of retained surgical items) and helps health care professionals ensure that best practices are followed.
Audiovisual > Audiovisual Presentation
Producer: Partnership for Patient Safety & Risk Management Foundation. Chicago, IL: Partnership for Patient Safety; 2000.
This video, produced by the Partnership for Patient Safety and the Harvard Risk Management Foundation, presents a series of missteps involving a healthy obstetric patient and her unborn infant. Based on actual facts drawn from the experience of the Risk Management Foundation of the Harvard Medical Institutions, this 18-minute film illustrates the value of having a systems awareness in medicine. Deeper explorations of teamwork, hand-offs, communication skills, and managing the authority gradient provide rich examples for viewers. Parts 2 and 3 complete the video series.
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.
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.
Weise E. USA Today. May 18, 2005.
Zipperer LA, Cushman S, eds. Chicago, IL: National Patient Safety Foundation; 2001. ISBN: 1579471889.
The editors present eight chapters covering key areas of patient safety: epidemiology of error, reporting of error, lessons from anesthesiology, emotional response to error, human factors, medication error, and general studies of error and administrative issues.
Wojcieszak D. Patient Safety Qual Healthc. May/June 2005;2:6, 8-9.
The author, who lost his brother to medical error, reflects on his family's frustrating experience with the hospital and legal system. He proposes that the medical profession can learn valuable lessons from the engineering safety culture.
Web Resource > Multi-use Website
2410A Hyde Park Road, Jefferson City, MO 65109.
The Missouri Center for Patient Safety is dedicated to improving patient safety in Missouri by applying evidence-based methods and best practices. The private, not-for-profit corporation was established by the Missouri State Medical Association, the Missouri Hospital Association, and Primaris, a quality improvement organization.
Scobie S, Thomson R. London, England: National Patient Safety Agency; 2005.
Created in 2001 to institute changes in health care across the United Kingdom, the National Patient Safety Agency (NPSA) presents their first report of patient safety incidents. The two-part report begins with a general discussion of incident reporting, the basis for a national reporting system, and the development of the Patient Safety Observatory. The second part builds on this framework by discussing how the acquired data can be used and translated into safer health care strategies. The report itself encompasses more than 85,000 collected incident reports with analysis, comparisons, and case studies to illustrate important safety issues for future efforts. This represents the first of a series of expected reports from NPSA on patient safety data to be published.
Kowalczyk L. The Boston Globe. July 24, 2005.
This article reports on a proposed disclosure policy among Harvard Medical School teaching hospitals. The policy would outline a process for discussing error with patients and for training physicians on how to apologize.
Gaul GM. The Washington Post. July 29, 2005:A06.
This article presents the newly passed Patient Safety and Quality Improvement Act of 2005 in comparison to mandatory, state-based reporting initiatives.
Ostrom CM. Seattle Times. September 13, 2005;Local News:B3
This article reports on how one family and hospital will use personal tragedy to create awareness in practitioners of the importance of accurate labeling in hospitals.
Legislation/Regulation > Federal Legislation
S 1784, 109th Cong, 1st Sess (2005).
This bill, introduced to the Senate by Senators Clinton (D-NY) and Obama (D-IL), proposes a program under the direction of the U.S. Department of Health and Human Services to a) require hospitals to disclose errors to patients and offer reasonable financial settlements where appropriate; b) create a national patient safety database, comprised of confidential reports from health care institutions; and c) protect any statements about and apologies for errors that providers make to patients from being used in a later malpractice action.