Narrow Results Clear All
- Communication between Providers 5
- Culture of Safety 5
Education and Training
- Students 1
- Error Reporting and Analysis 13
- Human Factors Engineering 6
- Legal and Policy Approaches 8
- Logistical Approaches 5
- Quality Improvement Strategies 9
- Specialization of Care 2
- Teamwork 1
- Technologic Approaches 3
- Device-related Complications 6
- Diagnostic Errors 1
- Discontinuities, Gaps, and Hand-Off Problems 5
- Identification Errors
- Interruptions and distractions 1
- Medical Complications
- Medication Safety 14
- Psychological and Social Complications 2
- Surgical Complications 19
- Transfusion Complications 3
- Family Members and Caregivers 1
- Health Care Executives and Administrators 21
Health Care Providers
- Nurses 2
- Non-Health Care Professionals 10
- Patients 9
Search results for ""
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; October 2001. AHRQ Publication No. 01-0017.
A brief presentation of "pearls" to allow consumers to take an active role in preventing medical errors.
Feldman R. The Washington Post. May 2, 2006:HE01.
In this article, a nurse shares her firsthand account of what it was like to be a surgical patient and the surprising safety and quality shortcomings she encountered during her hospital stay.
Blum A. Business Week. August 15, 2006.
This article discusses how hospital design, including standardized operating rooms, better ventilation systems, and green design can improve patient safety and decrease costs.
Kapadia R. Smart Money. October 2006;15:112-114.
This article provides tips for consumers to help keep their hospital care as safe and hassle-free as possible.
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.
Szabo L. USA Today. February 5, 2007.
This article suggests ways for patients to play a proactive and informed role in their own safe care. A video entitled "Things you should know before entering a hospital" accompanies the article.
Oakbrook Terrace, IL: The Joint Commission; March 2007.
This report reveals that the overall quality of care delivered by US hospitals improved steadily between 2003 and 2005, as measured by adherence to evidence-based treatments for myocardial infarction, congestive heart failure, and pneumonia. Adherence to the Joint Commission's National Patient Safety Goals, which include measures to prevent wrong-site surgery and promote medication reconciliation, was also measured. Although results on these measures showed a more mixed picture, the report cautions that changes in measurement during the study period limit interpretability of the results.
May H. Salt Lake Tribune. August 18, 2008.
This article examines 2007 state health data on never events in the context of a label-related medical error that resulted in a recent death.
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.
Sydney, Australia: Australian Commission on Safety and Quality in Health Care; 2008. ISBN: 9780980346275.
This report compiles public and private data to provide insight into the quality and safety of patient care in Australian hospitals.
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.
Adverse Events in Hospitals: Care Study of Incidence Among Medicare Beneficiaries in Two Selected Counties.
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; December 2008. Report No. OEI-06-08-00220.
The Center for Medicare and Medicaid Services (CMS) no longer reimburses hospitals for the costs associated with certain preventable adverse events, many (but not all) of which are considered never events. This report from the federal Office of the Inspector General (OIG) examines the adverse events in a sample of Medicare beneficiaries. As outlined in a previous report, the OIG chose to evaluate the overall incidence of adverse events, including "no pay for errors" conditions, never events, and all other adverse consequences of hospitalization, including non-preventable adverse events. Therefore, the 15% overall incidence of adverse events found in this study should be interpreted with caution. Less than 1% of patients experienced a never event, and approximately 4% experienced a condition on CMS's no pay for errors list.
National Patient Safety Agency. London, UK: National Reporting and Learning Service; 2009.
This report from the United Kingdom is intended to guide Primary Care Trusts in implementing never events policies for 2009-2010.
Tools/Toolkit > Multi-use Website
Washington State Hospital Association.
This Web site provides toolkits and information to help Washington hospitals adopt standard practices for emergency code calls, surgery preparation, isolation precautions, and wristband use.
Journal Article > Commentary
Saufl NM. J Perianesth Nurs. 2009;24:114-118.
This commentary provides background on the development of the Joint Commission's 2009 National Patient Safety Goals and summarizes the goals set for the hospital environment.
Gardner E. Mod Healthc. May 18, 2009;39:28-31.
This article describes how one health system markedly improved its quality and safety by applying a safety technique used in the nuclear power industry.
Journal Article > Study
Incident reporting practices in the preanalytical phase: low reported frequencies in the primary health care setting.
Söderberg J, Grankvist K, Brulin C, Wallin O. Scand J Clin Lab Invest. 2009;69:731-735.
Laboratory technicians reported very low usage of incident reporting systems, primarily due to lack of time available to complete reports.
Journal Article > Commentary
Understanding national coverage policies. Navigating the maze of HACs, serious reportable events, and wrong surgical sites.
Cook J, D'Amato C, Garrett G, Ruhnau-Gee B, Hyde L, Novak N. J AHIMA. 2009;80:62-64.
The authors explain reporting and coding requirements for various types of sentinel event data and describe how these affect coverage.
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.