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- Error Reporting and Analysis 5
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Web Resource > Database/Directory
Centers for Medicare and Medicaid Services.
This website provides consumers with detailed information about the past performance of every Medicare- and Medicaid-certified nursing home in the country. Additional resources available at the site help with other nursing home selection issues. Information is provided in English, Spanish, and Chinese.
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.
Cohen B. "Morning Edition." National Public Radio. August 1, 2005.
This audio segment reports on a new prescription bottle that allows physicians and pharmacists to record verbal instructions, which patients can then retrieve by pushing a button on the bottle.
Bailey B, Sevrens Lyons J. The Mercury News. November 27, 2005.
This article reports on several errors that occurred at hospitals in California and discusses the state's regulatory system.
Dembner A. Boston Globe. July 3, 2006;Health Science section:A1.
This article reports on the movement to improve care in nursing homes in order to decrease unnecessary hospitalizations for elderly patients.
St. Paul, MN: Minnesota Department of Health; March 2019.
The National Quality Forum has defined 29 never events—patient safety problems that should never occur, such as wrong-site surgery and patient falls. Since 2003, Minnesota hospitals have been required to report such incidents. The 2018 report summarizes information about 384 adverse events that were reported and found pressure ulcers and invasive procedure events increased, while fall-related deaths decreased. Reports from previous years are also available.
Wolfe W. Minneapolis Star Tribune. February 28, 2007.
This article reports on three patient deaths due to errors at a state-owned nursing home for veterans.
Hamill SD. Pittsburgh Post-Gazette. April 18, 2010:A1.
This news piece details efforts to collect, analyze, and utilize state-wide reports on health care–associated infections in Pennsylvania.
Ackerman T. Houston Chronicle. November 23, 2012.
This newspaper article describes challenges that may precipitate underdiagnosis or misdiagnosis of Alzheimer disease and conditions with similar presenting symptoms.
Jones R. WXYZ. November 13, 2013.
This news piece reports on risks associated with medication delivery in nursing homes and reveals several incidents that resulted in significant patient harm.
Pierrotti A. USA Today. August 18, 2014.
Jaffe I, Renincasa R. Morning Edition. National Public Radio. December 8–9, 2014.
Overprescribing of medications is a common problem in nursing homes. This two-part radio segment reports on the inappropriate use of antipsychotic medications as a chemical restraint for patients with dementia. The first part introduces the issue and includes insights from families that have experienced harm due to the practice. The second segment discusses programs that the Centers for Medicare and Medicaid Services has put in place to address the problem through a more patient-centered approach to care and suggests strengthening penalties against organizations that overuse antipsychotics.
Ornstein C. Washington Post. July 12, 2015.
Anticoagulants are considered high-alert medications that if used ineffectively can result in patient harm. Reporting on an anticoagulant commonly used in nursing homes and patient harm linked to this medication, this newspaper article relates reasons doctors are reluctant to prescribe new drugs to older patients and challenges to monitoring and preventing such adverse drug events.
Schulte F, Lucas E, Mahr J. Kaiser Health News and Chicago Tribune. September 5, 2018.
Sepsis is a serious condition that can be fatal if it is not promptly diagnosed and treated. This news article reports on systemic factors in nursing homes such as poor staffing and communication with families that contribute to unmanaged pressure ulcers and sepsis that result in hospital admissions and death. A WebM&M commentary discussed a case involving a patient who had a pressure ulcer and sepsis in long-term care.