Narrow Results Clear All
- Communication Improvement 4
- Culture of Safety 2
- Education and Training 7
Error Reporting and Analysis
- Never Events 13
- Error Reporting
- Human Factors Engineering 5
- Legal and Policy Approaches 11
- Logistical Approaches 2
- Quality Improvement Strategies 16
- Specialization of Care 1
- Clinical Information Systems 2
- Device-related Complications 4
- Discontinuities, Gaps, and Hand-Off Problems 2
- Identification Errors 4
- Medical Complications
- Medication Safety 7
- Nonsurgical Procedural Complications 2
- Surgical Complications 15
- Transfusion Complications 2
- Internal Medicine
- Surgery 5
- Nursing 1
- Health Care Executives and Administrators 31
Health Care Providers
- Nurses 1
- Non-Health Care Professionals 18
- Patients 9
- Europe 3
- Canada 2
Search results for ""
Inspiring Ideas and Celebrating Successes: A Guidebook to Leading Patient Safety Practices in Ontario Hospitals.
OHA Patient Safety Support Service. Toronto, Ontario, Canada: Ontario Hospital Association; 2006.
This report shares successful patient safety strategies employed in Ontario hospitals to address medication safety, patient incident management, infection issues, and administrative process improvements.
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.
Ottawa, ON, Canada: Canadian Institute for Health Information; August 14, 2007.
Using survey data as well as information on patient safety indicators, this report provides an update on the frequency of certain types of errors and incidents in Canada.
Kowalczyk L. Boston Globe. September 17, 2007;Metro section:1A.
This article reports on how numerous Massachusetts hospitals have implemented policies to waive charges for the set of serious errors categorized as never events.
Lerner M. Star Tribune. September 18, 2007;News section:5B.
This article reports on Minnesota's adoption of a policy for hospitals to not charge patients or insurers for never events or consequent treatment.
More states shred bills for awful medical errors: patients in 23 states will no longer pay for certain mistakes, hospitals say.
Aleccia J. MSNBC News. August 12, 2008.
This article reports on the implementation and expansion of several states' non-payment policies for medical mistakes in light of similar policies set by Medicare and private insurance companies.
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.
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.
ASQ Quarterly Quality Report. Milwaukee, WI: American Society of Quality; October 2008.
This report describes strategies for health care institutions to prevent never events, based on results of a 2008 survey of quality professionals.
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.
Journal Article > Study
Kernisan LP, Lee SJ, Boscardin WJ, Landefeld CS, Dudley RA. JAMA. 2009;301:1341-1348.
The Leapfrog Group has been a major driver of patient safety efforts—more than 1000 hospitals have committed to implementing its recommendations for computerized provider order entry, intensivist coverage for critically ill patients, evidence-based referral for certain diagnoses, and implementation of the National Quality Forum's (NQF) Safe Practices. A prior study found that hospitals that had implemented at least one Leapfrog practice tended to provide higher quality of care for specific diagnoses. However, in this study, adoption of the NQF safe practices did not correlate with reduced inpatient mortality. The authors note that many hospitals could score highly on the Leapfrog Hospital Survey but not fully implement or consistently follow safety recommendations, as the survey only measures a hospital's self-reported implementation of safety practices.
Fillo KT. Bureau of Health Care Safety and Quality, Department of Public Health. Boston, MA: Commonwealth of Massachusetts; July 2018.
This report compiles patient safety data documented by Massachusetts hospitals. The latest numbers represent a modest decrease in serious reportable events recorded in acute care hospitals, from 1012 the previous year to 922. This presentation also includes events from ambulatory surgery centers. Previous years reports are also available.
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.
May H. Salt Lake Tribune. June 26, 2009.
Journal Article > Study
Reid M, Estacio R, Albert R. Am J Med Qual. 2009;24:520-524.
This study characterizes the types and severity of patient safety events at academic hospitals that were reported to a voluntary error reporting system.
Journal Article > Study
McNair PD, Luft HS, Bindman AB. Health Aff (Millwood). 2009;28:1485-1493.
A 2008 policy change by the Centers for Medicare and Medicaid Services (CMS) eliminated reimbursement for some preventable errors, including certain never events and hospital-acquired infections. This policy has catalyzed efforts to realign payment incentives and patient safety efforts, despite the fact that, as this article demonstrates, the actual financial effects of the policy are likely minimal. Based on California hospital discharge data, the authors estimate that the total nationwide Medicare payment reductions would amount to only $1.1 million yearly. The authors suggest several methods for strengthening the policy, including denying payments for readmissions associated with hospital-acquired complications. The implications of the CMS "no pay for errors" policy are further discussed in an AHRQ WebM&M perspective.
Trenton, NJ: New Jersey Department of Health and Senior Services; March 2012.
Journal Article > Study
Potential unintended consequences due to Medicare's "No Pay for Errors Rule"? A randomized controlled trial of an educational intervention with internal medicine residents.
Mookherjee S, Vidyarthi AR, Ranji SR, Maselli J, Wachter RM, Baron RB. J Gen Intern Med. 2010;25:1097-1101.
A 2008 policy change by the Centers for Medicare and Medicaid Services (CMS) eliminated reimbursement for certain preventable errors, including selected never events and hospital-acquired infections. The impact of the policy was debated, including the ability of providers and systems to accurately identify conditions present on admission. This study involved an educational intervention to assess the policy's impact on clinical practice among trainees. In a series of presented clinical vignettes, members of the intervention group, who received education about the new policy as part of the study, were less likely than participants who received no such education to select the most clinically appropriate response. While all the trainees acknowledged responsibility to understand CMS documentation rules and felt poorly trained to do so, their responses to the vignettes raised concern about the potential harm and unintended consequences caused by unnecessary testing and procedures that may result from the policy. The implications of the CMS policy are further discussed in an AHRQ WebM&M perspective.
Journal Article > Review
Taub N, Baker R, Khunti K, et al. Diabet Med. 2010;27:1322-1326.
This study found little research on safety improvement methods in the primary care of diabetes.
Wetzel TG. Health Data Manage. 2011 Feb;19:86, 88, 90 passim.
This article discusses how several health care organizations used health information technology to improve organizational transparency.