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- Communication Improvement 2
- Culture of Safety 3
- Education and Training 2
- Error Reporting and Analysis 4
- Human Factors Engineering 2
- Legal and Policy Approaches
- Logistical Approaches 1
- Quality Improvement Strategies 4
- Teamwork 1
- Diagnostic Errors 1
- Discontinuities, Gaps, and Hand-Off Problems 2
- Drug shortages 1
- Fatigue and Sleep Deprivation 1
- Identification Errors 1
- Medical Complications 1
- Medication Safety 3
- Psychological and Social Complications 2
- Surgical Complications 1
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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 > Interview
International Perspectives on Safety, May 2007
Sir Liam Donaldson, MD, MSc, is England's Chief Medical Officer, a post often referred to as "the Nation's Doctor" (similar to the role of the U.S. Surgeon General). Trained as a surgeon, Sir Liam has been an inspirational leader in public health and health care quality in the United Kingdom for two decades. He has also emerged as a world leader in the patient safety field, authoring or commissioning dozens of influential reports, and serving as the founding chair of the World Health Organization's World Alliance for Patient Safety. We spoke to him about patient safety from an international perspective.
World Health Organization.
This publication shares news related to the World Health Organization's Global Patient Safety Challenge.
Journal Article > Commentary
Emanuel EJ. JAMA. 2007;297:2131-2133.
The author discusses how changes in language used to describe health care reflect a shifting public perception of the US health care system. This shift involves increasing recognition that errors do occur and that the health care system is flawed.
Journal Article > Commentary
Dekker S. J Law Med Ethics. 2007;35:463-470.
The author analyzes one Swedish medication error incident that resulted in criminal charges against the nurse involved and discusses how the media contorted the assignment of blame for the failure.
Journal Article > Study
Rhodes P, Giles SJ, Cook GA, et al. Qual Saf Health Care. 2008;17:409-415.
Wrong-site surgery is a rare yet devastating outcome. Prevention strategies have focused on adoption of the Joint Commission's Universal Protocol and structured communication tools such as time outs. This study examined the impact of a national safety alert issued to all NHS hospital trusts in England and Wales about preventing wrong-site surgery. Investigators interviewed surgeons and senior nurses in the 12-15 months following the alert and discovered significant variation in the adoption of proposed recommendations. While the alert was associated with greater awareness and surgical marking of sites, the authors discuss the complex nature of change management around the new policy. A related commentary [see link below] discusses the broader context of efforts to eliminate wrong-site surgery. A past AHRQ WebM&M commentary discussed the factors contributing to a near-miss wrong-site surgery, and a recent commentary outlined the anatomy of a time out.
Chen PW. New York Times. April 18, 2013.
Wise S, Sears T. CBS 6 WTVR. October 24, 2013.
This news piece reports that caregivers at schools in Virginia are often nurse aides, secretaries, and administrators with insufficient medical knowledge.
Poll: Many Sick Americans Experience Significant Financial Problems and Report Their Care is not Well-Managed.
Princeton, NJ: Robert Wood Johnson Foundation, National Public Radio, and the Harvard School of Public Health. May 21, 2012.
This report describes findings from a poll that investigated how cost of care and health insurance affect patients' experiences of health care quality and safety in the United States.
Journal Article > Review
Fox ER, Sweet BV, Jensen V. Mayo Clin Proc. 2014;89:361-373.
Clark C. HealthLeaders Media. August 7, 2014.
Although California has collected an estimated $15 million in penalties from hospitals for adverse events, this news piece describes how much of the money has yet to be allocated or spent on safety improvement projects. Moreover, some state agencies have been reluctant to provide specific data to projects that have already been funded.
Flatten M. Washington Examiner. August 18–22, 2014.
Journal Article > Review
Wu AW, Kavanagh KT, Pronovost PJ, Bates DW. J Patient Saf. 2014;10:181-185.
In light of an unreported conflict of interest that might have affected recommendations for chlorhexidine use to reduce risk of central line–associated infections, this review examines articles written or coauthored by Dr. Charles Denham to determine whether undeclared conflicts of interest could have influenced conclusions, selections, and recommendations in published research. The authors emphasize the need to identify and address conflicts of interest and outline strategies to reduce risk of undisclosed conflicts which may in turn affect validity of published evidence.
Landro L. Wall Street Journal. May 9, 2016.
Closed claims have been considered a source for adverse event data for years, and recently such data has been utilized to inform safety improvement work. This newspaper article reviews several organizational efforts that use claims data to determine factors that contribute to failure and strategies to address them, including process redesign and enhanced patient education.
Ghaferi AA, Myers C, Sutcliffe KM, Pronovost PJ. Harv Bus Rev. July/August 2016;94.
Achieving high reliability is a recognized goal for health care organizations. Reviewing current technical and standardization enhancements to augment quality and safety in surgery, this article explores how implementing high reliability concepts could further improve safety in surgical care over time.