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- Communication Improvement 2
- Culture of Safety 3
- Education and Training 1
- Error Reporting and Analysis 6
- Human Factors Engineering 2
- Legal and Policy Approaches 3
- Logistical Approaches 2
- Quality Improvement Strategies 7
- Specialization of Care 1
- Technologic Approaches 2
- Device-related Complications 1
- Diagnostic Errors 2
- Discontinuities, Gaps, and Hand-Off Problems 1
- Fatigue and Sleep Deprivation 1
- Identification Errors 5
- Medical Complications
- Medication Safety 5
- Nonsurgical Procedural Complications 1
- Surgical Complications
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Cases & Commentaries
- Web M&M
Verna C. Gibbs, MD; September 2003
A patient dies from infection and complications months after surgery; a retained sponge is found at autopsy.
Perspectives on Safety > Perspective
with commentary by Ashish K. Jha, MD, MPH, The Transformation of Patient Safety at the VA, September 2006
Five years after the landmark Crossing the Quality Chasm report by the Institute of Medicine (IOM), the quality and safety of health care in the United States remains far from ideal.(1) It is easy to feel pessimistic. Can health care organizations really...
Tools/Toolkit > Fact Sheet/FAQs
Rockville, MD: Agency for Healthcare Research and Quality; Revised December 2009. AHRQ Publication No. 10-M008.
This tip sheet provides 10 practical steps hospitals can undertake to improve patient safety, based on research funded by the Agency for Healthcare Research and Quality. The tips can be grouped into three areas: 1) reducing health care-acquired infections and retained surgical instruments through use of specific clinical practices; 2) improving drug safety by ensuring access to accurate drug information; and 3) improving the culture of safety through appropriate staffing and work hours for nurses and residents. These tips are based on high-quality research studies documenting the effectiveness of these interventions at reducing errors and improving safety for a broad range of patients.
Journal Article > Study
Do the AHRQ Patient Safety Indicators flag conditions that are present at the time of hospital admission?
Bahl V, Thompson MA, Kau T-Y, Hu HM, Campbell DA Jr. Med Care. 2008;46:516-522.
The Agency for Healthcare Research and Quality's Patient Safety Indicators (PSIs) were designed to reflect the quality of inpatient care by triggering cases for review using administrative data and examining potentially preventable complications. With an increasing focus on withholding payment for complications of care not present on admission (POA), efforts to make this important distinction continue. This study applied the use of PSIs with and without a POA variable and discovered that event rates were significantly lower for five PSIs using the added variable (decubitus ulcer, foreign body left in, selected infections due to medical care, and postoperative derangements and thromboembolic events). These findings suggest that use of standard PSIs will overstate the number of hospital complications in failing to take into account those clearly POA. The authors conclude that unadjusted PSIs should not be used to profile hospital performance or determine reimbursement.
Journal Article > Commentary
Pronovost PJ, Goeschel CA, Wachter RM. JAMA. 2008;299:2197-2199.
In October 2008, Medicare will put into effect a new policy that withholds payment for eight preventable complications of care, with plans already in place to expand this list in 2009. This initiative has prompted several discussions in the safety community, ranging from the business case for adopting such a policy to whether any of the targeted conditions can be accurately identified as present on admission. This commentary further explores the basis of Medicare's efforts and focuses on criteria that should be considered when withholding payment for complications of care. The authors provide a framework that requires each proposed complication to be important, measurable, and truly preventable to meet the burden of proof for inclusion. Only foreign objects retained after surgery and catheter-related blood stream infections serve as "wise and just" complications based on their assessment. While the authors acknowledge the opportunity for Medicare to align payment incentives and stimulate improvements in quality and reduce costs, they caution against rapid adoption and a failure to carefully evaluate the benefits and risks of the initiative.
Herper M, Lindner M. Forbes. August 25, 2008.
This article discusses common medical complications and care failures, and provides an annotated picture gallery of several hospital complications and how they can be prevented.
ASQ Quarterly Quality Report. Milwaukee, WI: American Society of Quality; October 2008.
This report describes strategies for health care institutions to prevent never events, based on results of a 2008 survey of quality professionals.
Journal Article > Study
Incidence of adverse events related to health care in Spain: results of the Spanish National Study of Adverse Events.
Aranaz-Andrés JM, Aibar-Remón C, Vitaller-Murillo J, et al. J Epidemiol Community Health. 2008;62:1022-1029.
This retrospective cohort study analyzed inpatient cases associated with adverse events (AEs) and found that the most frequent events were related to medications, hospital infections, and technical problems during a procedure. The authors point out that their AE rates mirror those described in Canada and Australia but are higher than those reported in the highly regarded Harvard Medical Practice Study.
National Priorities Partnership. Washington, DC: National Quality Forum; 2008. ISBN: 1933875194.
This report resulted from a consensus program involving 28 national organizations that sought to outline goals for improving the US health care system and share examples of such efforts in patient safety and other identified areas.
Journal Article > Study
Bottle A, Aylin P. Qual Saf Health Care. 2009;18:303-308.
The Agency for Healthcare Research and Quality's Patient Safety Indicators were found to have limited utility in screening for patient safety problems in British hospitals.
Web Resource > Multi-use Website
The Joint Commission.
The Joint Commission has traditionally focused on accreditation of health care organizations and, through its Joint Commission Resources arm, on quality improvement (QI) in areas related to its accreditation functions. In the first major initiative under the leadership of new president Dr. Mark Chassin, The Joint Commission launched this Center, which will focus on applying rigorous QI methods to improve safety in a number of challenging areas (the first three are hand hygiene, handoff communication, and preventing wrong site surgery) and disseminating the lessons from these efforts. This Web site provides more information about the Center and its goals.
Journal Article > Review
Cao LY, Taylor JS, Vidimos A. Dermatol Online J. 2010;16:3.
This review examines numerous safety issues relevant to outpatient dermatology practice, including medication errors, diagnostic errors, office-based surgery, wrong-site procedures, and laser safety.
Web Resource > Government Resource
Centers for Medicare & Medicaid Services.
The Centers for Medicare and Medicaid Services (CMS) provides consumers with publicly available information on the quality of Medicare-certified hospital care through this Web site. The site includes specific information for both patients and hospitals on how to use the data to guide decision-making and improvement initiatives. Most recently, listings from the Hospital-Acquired Condition Reduction Program (HACRP) and data on Department of Veterans Affairs hospitals were added to the reports available.