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- Study 5
- Book/Report 25
- Legislation/Regulation 2
- Newspaper/Magazine Article 4
- Special or Theme Issue 1
- Toolkit 1
- Web Resource 16
- Award 1
- Press Release/Announcement 1
- Communication Improvement 2
- Culture of Safety 4
- Education and Training 2
- Error Reporting and Analysis
- Human Factors Engineering 2
Legal and Policy Approaches
- Regulation 12
- Quality Improvement Strategies 13
- Teamwork 1
- Technologic Approaches 5
- Transparency and Accountability 2
- Device-related Complications 4
- Discontinuities, Gaps, and Hand-Off Problems 2
- Medical Complications 9
- Medication Safety 5
- Nonsurgical Procedural Complications 1
- Psychological and Social Complications 1
- Surgical Complications 3
- Australia and New Zealand 1
- Europe 3
- Canada 2
Search results for ""
Ebright PR, Rapala K. Indianapolis, IN: Center for Urban Policy and the Environment; September 2005:1-7.
This brief report discusses important issues for policy makers in developing a statewide incident reporting system.
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.
Aspden P, Corrigan JM, Wolcott J, Erickson SM, eds for the Committee for Data Standards for Patient Safety, Institute of Medicine. Washington, DC: The National Academies Press; 2004. ISBN: 030909776.
Robust information systems serve as a backbone for both preventing medical error and learning from it. The authors submit that a national information infrastructure will facilitate immediate access to patient information and decision support mechanisms. They also suggest that a byproduct of the infrastructure will be a consistent method for managing patient safety data and the ability to capture it in real time as a result of care.
Tools/Toolkit > Multi-use Website
Portland, ME: National Academy for State Health Policy.
This online toolkit provides sample documents, policies, and Web site links related to the 27 states that have implemented adverse event reporting initiatives.
Web Resource > Government Resource
New Jersey Department of Health and Senior Services.
This Web site supports the data collection and educational initiatives associated with New Jersey's incident reporting program. The site includes reporting forms, instructions, and a patient safety newsletter.
Journal Article > Commentary
Feder HM. J Health Care Compliance. May/June 2006;8:49-50, 80.
This article briefly discusses the role of patient safety organizations (PSOs) as stipulated by the Patient Safety and Quality Improvement Act of 2005 and issues related to privacy, confidentiality, and impact on state reporting systems.
Journal Article > Commentary
Clinton HR, Obama B. N Engl J Med. 2006;354:2205-2208.
This commentary is written by Senators Hillary Rodham Clinton (D-NY) and Barack Obama (D-IL), who coauthored the National Medical Error Disclosure and Compensation (MEDiC) Act. Providing context for the bill, the senators advocate for necessary improvements in patient safety and the medical liability environment through a series of important and interdependent strategies. These include reducing the rates of preventable patient injuries, promoting open communication between physicians and patients, ensuring patients' access to fair compensation for legitimate medical injuries, and reducing liability insurance premiums for providers. The senators further discuss the implications of each approach and specifically outline the major provisions of the bill, including how it will foster and promote the necessary improvement efforts.
Journal Article > Commentary
Constitutional arguments in favor of modifying the HCQIA to allow the dissemination of physician information to healthcare consumers.
Chernitsky LA. Wash Lee Law Rev. Spring 2006;63:737-776.
The author presents a legal discussion on public access to physician information, arguing that Congress should allow consumers to access certain information while still protecting error information in order to promote error reporting.
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.
Office of the Inspector General. Washington, DC: US Department of Health and Human Services; September 2006. Report No. OEI-09-04-00350.
This report presents findings from an investigation into the reporting of and response to restraint and seclusion-related deaths.
Award > Award Recipient
Rabinowitz ABK, Clarke JR, Marella W, et al. Jt Comm J Qual Patient Saf. 2006;32:676-681.
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.
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.
Legislation/Regulation > New Jersey Legislation
New Jersey Legislature. A4327 (2007).
This bill amends a previous law by requiring that serious preventable adverse events be reported to the New Jersey Department of Health and Senior Services and that a list of these errors and where they occurred be publicly available.
Legislation/Regulation > Pennsylvania Legislation
General Assembly of Pennsylvania. SB968 (2007).
This bill requires that Pennsylvania hospitals and nursing homes implement an internal infection control plan and report hospital-acquired infections.
Federal Register. February 12, 2008;73:8112-8183.
These proposed rules seek to support the implementation of portions of the Patient Safety and Quality Improvement Act of 2005 including how entities are defined as a patient safety organization (PSO) and how PSOs will collect and protect safety incident data. The comment period on the proposed rules is now closed.
Rosenthal J, Takach M. Portland, ME: National Academy for State Health Policy; 2007. Publication No. 2007-301.
Highlighting the large increase in state adverse event reporting systems, this report finds that states are concentrating on standardization, using data collected to improve quality, and reporting the data publicly.
Journal Article > Study
The limits of knowledge management for UK public services modernization: the case of patient safety and service quality.
Currie G, Waring J, Finn R. Public Admin. 2008;86:363-385.
This article analyzes the implementation of the United Kingdom's error reporting system, the National Reporting and Learning System, and addresses the cultural conflicts between physicians, nurses, and managers inherent in implementing such a system.
Health-Care-Associated Infections in Hospitals: An Overview of State Reporting Programs and Individual Hospital Initiatives to Reduce Certain Infections.
Washington, DC: United States Government Accountability Office; September 2008. Publication GAO-08-808.
This report describes state reporting programs for health care–associated infection (HAI), hospital initiatives to reduce MRSA (methicillin-resistant Staphylococcus aureus), and challenges encountered in HAI reduction.