Narrow Results Clear All
- Patient Safety Primers 1
- Perspectives on Safety 1
- Commentary 13
- Review 8
- Study 53
- Slideset 1
- Book/Report 27
- Legislation/Regulation 2
- Newspaper/Magazine Article 23
- Special or Theme Issue 3
- Toolkit 1
- Web Resource 21
- Press Release/Announcement 3
- Communication Improvement 16
- Culture of Safety 12
Education and Training
- Students 1
Error Reporting and Analysis
- Error Analysis 16
- Never Events 31
- Human Factors Engineering 15
Legal and Policy Approaches
- Regulation 12
- Logistical Approaches 4
- Policies and Operations 1
- Quality Improvement Strategies 38
- Research Directions 1
- Specialization of Care 6
- Clinical Information Systems 8
- Transparency and Accountability 2
- Device-related Complications 17
- Diagnostic Errors 7
- Discontinuities, Gaps, and Hand-Off Problems 8
- Fatigue and Sleep Deprivation 2
- Identification Errors 10
- Delirium 1
- Medication Errors/Preventable Adverse Drug Events 29
- Nonsurgical Procedural Complications 4
- Psychological and Social Complications 9
- Surgical Complications 35
- Transfusion Complications 4
- Internal Medicine 66
- Nursing 11
- Pharmacy 1
- Family Members and Caregivers 1
- Health Care Executives and Administrators 108
Health Care Providers
- Nurses 10
Non-Health Care Professionals
- Media 1
- Patients 27
- Australia and New Zealand 5
- Europe 20
- Canada 5
United States of America
United States Federal Government
- Department of Health and Human Services (HHS) 16
- United States Federal Government 20
Search results for ""
2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted From 2010 to 2013.
Rockville, MD: Agency for Healthcare Research and Quality; October 2015. AHRQ Publication No.16-0006-EF.
Hospital-acquired conditions (HACs), some of which are never events, have been an important focus of patient safety initiatives, with reporting requirements and Medicare nonpayment leading to significant efforts to prevent these conditions. This update to a prior report from AHRQ details and confirms the declining rates in HACs between 2010 and 2013. The analysis indicated that hospitalized patients experienced 1.3 million fewer HACs over the 3 years (2011–2013) than if the HAC rate had remained at the 2010 level. Consequently, the report estimates a $12 billion savings in health care costs and 50,000 fewer hospital patient deaths. These improvements coincided with nationwide efforts to reduce adverse events, such as the Partnership for Patients initiative and Medicare payment reform. The remaining burden of HACs suggests continued investment in this patient safety problem is needed.
Leeds, UK: Clinical Support Audit Unit, Health and Social Care Information Centre. December 9, 2015. ISBN: 9781783865697.
The NHS Safety Thermometer is a tool developed by the National Health Service to facilitate staff participation in measuring patient harm in various care environments. This report explores the data collected on four types of health care–acquired conditions (pressure ulcers, falls, catheter–associated urinary tract infections, and venous thromboembolisms) in NHS patients over a 1-year period.
Preventable tragedies: superbugs and how ineffective monitoring of medical device safety fails patients.
US Senate Health, Education, Labor, and Pensions Committee. January 13, 2016.
Insufficient sterilization of duodenoscopes and other medical equipment has been linked to health care–associated infection outbreaks. This report summarizes findings from a government investigation into existing methods for monitoring and reporting device problems and provides recommendations for Congress, hospitals, and the Food and Drug Administration to augment identification and prevention of safety issues associated with medical devices.
Journal Article > Study
Disclosing large scale adverse events in the US Veterans Health Administration: lessons from media responses.
Maguire EM, Bokhour BG, Asch SM, et al. Public Health. 2016;135:75-82.
Large-scale adverse events can diminish public trust. According to this qualitative analysis of print, broadcast, and social media reports associated with certain infection control lapses in the Veterans Affairs health system, media reports did not convey specific aspects of error disclosure, such as apologies and lessons learned. Investigators also found that comments from hospital officials focused on providing factual information, while quotes from elected officials were largely negative. This study highlights the continuing need to follow evidence-based disclosure practices when interacting with media after adverse events.
Journal Article > Review
Jackson D, Hutchinson M, Barnason S, et al. J Nurs Manag. 2016;24:902-914.
McNeill R, Nelson DJ, Abutaleb Y. Reuters Investigation. September 7, 2016.
Antimicrobial resistance is a pervasive threat to patient safety. This news article discusses incidents involving methicillin-resistant Staphylococcus aureus (MRSA) infection to spotlight the need for health care to develop system-level approaches to measuring the problem and enforce regulations designed to prevent health care–associated infections. A PSNet perspective described one nurse's experience with MRSA as a patient.
National Scorecard on Rates of Hospital-Acquired Conditions 2010 to 2015: Interim Data From National Efforts to Make Health Care Safer.
Rockville, MD: Agency for Healthcare Research and Quality; December 2016.
Medicare nonpayment and reporting requirements have stimulated health care organizations to focus on reducing hospital-acquired conditions (HACs) such as health care–associated infections and never events. The Agency for Healthcare Research and Quality regularly tracks HAC rates, including rates of adverse drug events, catheter-associated urinary tract infections, central line–associated bloodstream infections, falls, obstetric adverse events, pressure ulcers, surgical site infections, ventilator-associated pneumonias, and postoperative venous thromboembolisms. According to data from the AHRQ National Scorecard, HACs have decreased by 21% between 2010 and 2015. This represents a total of 3.1 million fewer HACs contracted by hospitalized patients over 5 years, saving an estimated 125,000 lives and $28 billion. These findings represent substantial progress and support the success of incentives designed to eliminate HACs as a source of patient harm.
Web Resource > Government Resource
Centers for Disease Control and Prevention.
Jewett C. Kaiser Health News. May 9, 2017.
The Centers for Medicare and Medicaid Services decision to withhold payment for certain hospital-acquired conditions has prompted widespread efforts to prevent such events. This news article reports on an evaluation by the Office of Inspector General that found regulator review of hospital-acquired infection reports submitted to Medicare to be insufficient, which hinders hospitals' ability to learn from factors that contribute to infections.
Journal Article > Commentary
Growdon ME, Shorr RI, Inouye SK. JAMA Intern Med. 2017;177:759-760.
This commentary discusses unintended consequences of the well-intentioned strategy of keeping older adults in bed while hospitalized to reduce falls, a never event. The authors suggest that immobilizing patients is not the answer to fall prevention and advocate for hospitals to promote patient mobility as a routine part of care.
Journal Article > Commentary
Ethical considerations on disclosure when medical error is discovered during medicolegal death investigation.
Wolf DA, Drake SA, Snow FK. Am J Forensic Med Pathol. 2017;38:294-297.
Quick Safety. March 27, 2018;(40):1-2.
Falls are a common patient safety concern for adults but are rarely discussed as a threat to newborn safety. This newsletter article provides a definition for a newborn fall or drop, highlights factors that increase risks of such incidents, and offers recommendations to augment safety such as rounding to monitor parent fatigue and reporting of events to inform improvements.
Journal Article > Commentary
Addiss DG, Amon JJ. Health Hum Rights. 2019;21:19-32.
Although disclosure and apology for mistakes in medical care are recommended, less is known about use of such approaches for overarching system failures. This commentary explores the use of apology in global health programs. The authors use case studies to highlight ethical, legal, and human rights principles that can be challenged when intervention design and implementation result in unintentional harm.
Journal Article > Review
Cooper J, Williams H, Hibbert P, et al. Bull World Health Organ. 2018;96:498-505.
The World Health Organization International Classification for Patient Safety enables measurement of safety incident severity. In this study, researchers describe how they adapted the system to primary care. Their harm severity classification emphasizes psychological harm, hospitalizations, near misses, and uncertain outcomes in addition to traditional markers of harm.
Journal Article > Study
Al Mohajer M, Joiner KA, Nix DE. Acad Med. 2018;93:1827-1832.
The Hospital-Acquired Condition Reduction Program (HACRP) was established by the Centers for Medicare and Medicaid Services (CMS) and withholds payment to hospitals for several hospital-acquired conditions deemed to be preventable sources of patient harm. Prior research has shown that teaching hospitals, hospitals caring for more complicated and high-risk patients, and safety-net hospitals may be more likely to experience financial penalties under HACRP compared to nonteaching hospitals caring for less sick patients. These findings raised concerns regarding the possible unintended consequences related to pay-for-performance. Researchers sought to identify factors associated with HACRP performance and penalties. They found that teaching institutions and hospitals with higher case-mix index, length of stay, and those located in the Northeast or Western United States were more likely to receive penalties under the CMS program. A previous WebM&M commentary discussed the unintended consequences associated with publicly reported health care quality measures.
Peskin SM. New York Times. October 4, 2018.
Error disclosures are difficult but important conversations that can have negative consequences for patients, clinicians, and organizations, even when they are done appropriately. This newspaper article offers insights from a doctor who experienced both sides of disclosure, as a physician disclosing an error and as a patient whose physician missed a complication, and discusses how to manage relationships once clinical mistakes are recognized.
Special or Theme Issue
Health Aff (Millwood). 2018;37:1723-1908.
The Institute of Medicine report, To Err Is Human, marked the founding of the patient safety field. This special issue of Health Affairs, published 20 years after that report, highlights achievements and progress to date. One implementation study of evidence-based surgical safety checklists demonstrated that leadership involvement, intensive activities, and engagement of frontline staff are all critical to successful adoption of safety practices. Another study demonstrated that communication-and-resolution programs either decreased or did not affect malpractice costs, providing further support for implementing such programs. Experts describe the critical role of human factors engineering in patient safety and outline how to enhance the use of these methods. The concluding editorial by David Bates and Hardeep Singh points to progress in reducing hospital-acquired infections and improving medication safety in acute care settings and highlights remaining gaps in the areas of outpatient care, diagnostic errors, and electronic health record safety. In the related information, the Moore Foundation provides free access to five articles in this special issue.
Journal Article > Study
Smith S, Snyder A, McMahon LF Jr, Petersen L, Meddings J. Health Aff (Millwood). 2018;37:1787-1796.
Hospital-acquired pressure ulcers (HAPUs) are considered a never event, represent a significant source of patient harm, and can result in loss of payment to hospitals. In this study, researchers analyzed administrative data from 3 states for 2009 to 2014. The HAPU incidence they found was about one-twentieth of the HAPU incidence detected using chart review. In addition, while both chart review data and administrative data showed a reduction in HAPU incidence for the study period, the decline using administrative data was almost entirely due to a decrease in the incidence of lower stage pressure ulcers. The authors suggest that using clinical data from chart review and taking ulcer severity into account may yield a more meaningful measurement strategy.
AHRQ National Scorecard on Hospital-Acquired Conditions Updated Baseline Rates and Preliminary Results 2014–2017.
Rockville, MD: Agency for Healthcare Research and Quality; January 2019.
Hospital-acquired conditions (HACs) represent a significant source of preventable harm to patients. The Centers for Medicare and Medicaid Services financially penalizes hospitals with increased numbers of HACs through the Hospital-Acquired Condition Reduction Program. This policy of nonpayment has prompted hospitals to focus significant resources on preventing HACs. This AHRQ report found a reduction in HACs from 99 per 1000 acute care discharges to 86 per 1000 discharges between 2014 and 2017, representing a decrease in 910,000 HACs and savings of $7.7 billion. Declines in certain HACs such as adverse drug events and Clostridium difficile infections were noted to be more significant as compared to others. A past WebM&M commentary highlighted the clinical significance of HACs and described an incident involving a patient who developed a pressure ulcer while in the hospital.