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Web Resource > Multi-use Website
Foundation for Health Care Quality, 705 2nd Avenue, Suite 703, Seattle, WA 98104.
This coalition supports a network of patient safety professionals to facilitate dialogue, promote initiatives on eliminating wrong-site surgery, and improve medication safety.
PA-PSRS Patient Saf Advis. December 2007;4:109, 112-123.
This article summarizes a state-level analysis that used site visits along with near miss and error reports to evaluate wrong-site surgeries.
PA-PSRS Patient Saf Advis. June 2009;6:39-45.
This piece identifies risk factors associated with retention of foreign objects and suggests several tactics to prevent its occurrence.
Journal Article > Study
Blanco M, Clarke JR, Martindell D. AORN J. 2009;90:215-222.
Office of Health Care Quality. Baltimore, MD: Maryland Department of Health and Mental Hygiene; 2018.
This annual report summarizes never events in Maryland hospitals over the previous year. From July 2016--June 2017, reported patient falls and pressure ulcers increased. The authors recommend several corrective actions to build on training and policy changes to guide improvement work, including improving use of hospital data to proactively manage risk and engaging hospital and departmental leaders in root cause analysis.