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- Communication Improvement 2
- Culture of Safety 1
- Error Reporting and Analysis
- Legal and Policy Approaches 2
- Quality Improvement Strategies 4
- Teamwork 1
- Technologic Approaches 1
- Device-related Complications 1
- Discontinuities, Gaps, and Hand-Off Problems 1
- Identification Errors 1
- Medical Complications 2
- Medication Safety 3
- Nonsurgical Procedural Complications 1
- Surgical Complications 1
Search results for ""
Journal Article > Study
Bennett CL, Nebeker JR, Lyons EA, et al. JAMA. 2005;293:2131-2140.
This article summarizes the structure, funding, organization, and methods of an independent and clinically based surveillance program identifying serious and unrecognized adverse drug events (ADEs). The authors provide a detailed account of the process involved, from investigating a possible serious ADE to disseminating their findings to the Food and Drug Administration (FDA), manufacturers, conferences, journals, and the news media. They also share initial results of their operations with details of 16 drugs associated with serious ADEs, including tabular display of the cases reported and the inconsistencies in the dissemination of safety information. The authors conclude by sharing potential implications of the program's efforts and how this surveillance method may provide additional opportunity to detect and prevent serious ADEs.
Rosenthal J, Booth M. Portland, ME: National Academy for State Health Policy; 2005.
This report, generated by the National Academy for State Health Policy, provides practical guidance and tools for states with existing reporting systems. The expert group that came together included data collectors, analysts, and users who aimed to develop strategies for improved collection, analysis, and feedback. The authors present key findings and emphasize that the quality improvement aspect of reporting systems is critical to success. Although the authors encourage greater use of reporting systems, a need exists for states to produce better-quality reports from their data to promote patient safety interventions. Additional initiatives from the report include development of a central Web-based repository of tools and resources that they plan to make available at their Web site.
Colburn D. The Oregonian. February 1, 2006:B1.
This article reports on the launch of Oregon's statewide voluntary incident reporting program to track medical error.
Office of the Inspector General. Washington, DC: US Department of Health and Human Services; August 2006. Report No. OEI-06-05-00060.
This report shares findings from an inspection of the FDA's National Drug Code Directory, which found that the directory is both incomplete and inaccurate in its listings of marketed prescription medications.
Gulliver D. Sarasota Herald Tribune. November 7, 2006:BS1.
This article reports on the death of a restrained patient and outlines the factors affecting the subsequent reporting of the event.
Falls Church, VA: TRICARE Management Activity, Office of the Assistant Secretary of Defense; 2006.
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.
Rojas-Burke J. Oregonian. January 30, 2007:B01.
This article reports on results from the first round of error data reported to the Oregon Patient Safety Commission voluntary reporting program.
Web Resource > Government Resource
Indiana State Department of Health.
This Web site provides background and information on Indiana's statewide incident reporting initiative.
Salt Lake City, UT: Utah Department of Health, Utah Hospitals & Health Systems Association, and HealthInsight; March 10, 2010.
This brief provides information on 101 sentinel events reported to the state of Utah in 2009. The report also includes background on efforts to address such incidents.
Journal Article > Study
Patient safety incidents associated with obesity: a review of reports to the National Patient Safety Agency and recommendations for hospital practice.
Booth CM, Moore CE, Eddleston J, Sharman M, Atkinson D, Moore JA. Postgrad Med J. 2011;87:694-699.
The obesity epidemic is considered an urgent public health issue in Europe and the United States. Although morbidly obese patients are prone to a variety of medical issues, no study to date has evaluated patient safety risks in this population. This retrospective analysis of errors voluntarily reported to the United Kingdom's National Patient Safety Agency documents more than 380 errors and near misses in which obesity was considered a contributing factor. The majority of errors were partly attributable to inadequate equipment for caring for such patients, particularly in the surgical and critical care environments. Based on these data, the authors advocate for multidisciplinary approaches to systematizing care for morbidly obese patients. The challenges of caring for obese patients are discussed in an AHRQ WebM&M commentary, which examined a case of an ultimately fatal delayed diagnosis in a morbidly obese woman.
Journal Article > Study
Serious adverse drug events reported to the FDA: analysis of the FDA Adverse Event Reporting System 2006–2014 database.
Sonawane KB, Cheng N, Hansen RA. J Manag Care Spec Pharm. 2018;24:682-690.
This retrospective study reviewed serious and fatal adverse drug events (ADEs) reported to the Food and Drug Administration between 2006 and 2014. Over the 9-year study period, the number of serious ADEs reported doubled and a small number of medications accounted for a significant number of serious and fatal ADEs.