Narrow Results Clear All
- Communication Improvement 5
- Culture of Safety 4
- Education and Training 7
Error Reporting and Analysis
- Never Events 15
- Error Reporting
- Human Factors Engineering 5
- Legal and Policy Approaches 15
- Logistical Approaches 2
- Quality Improvement Strategies 9
- Specialization of Care 2
- Technologic Approaches 4
- Transparency and Accountability 1
- Device-related Complications 4
- Discontinuities, Gaps, and Hand-Off Problems 3
- Identification Errors 8
- Medical Complications
- Medication Safety 11
- Nonsurgical Procedural Complications 2
- Psychological and Social Complications 2
- Surgical Complications
- Transfusion Complications 3
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...
Journal Article > Study
Chan DK, Gallagher TH, Reznick R, Levinson W. Surgery. 2005;138:851-858.
This study evaluated the capacity of 30 academic surgeons to discuss error scenarios, such as wrong-side surgery and retained sponges, with standardized patients. Investigators analyzed the conversations and discovered that 57% of the surgeons used the word "error" or "mistake," but less than half offered a verbal apology. The authors conclude that significant gaps exist between how physicians disclose medical errors and what patients expect in such conversations, thereby generating a need for educational intervention. The same authors previously wrote a commentary calling for professional action in disclosure of medical errors.
Levine S. Washington Post. July 18, 2006:B01.
This article reports on the efforts of one woman, whose mother was severely burned during a tracheostomy, to educate others about and reduce the risk of surgical fires.
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.
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.
Journal Article > Review
Hwang RW, Herndon JH. Clin Orthop Relat Res. 2007;457:21-34.
The authors discuss the financial incentives of improving patient outcomes as the business case for patient safety.
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.
Ostrom CM. Seattle Times. January 29, 2008;News section:A1.
This article discusses a voluntary initiative in the state of Washington to cease billing patients for costs associated with preventable errors.
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.
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.
Chasson L, compiler; Mahoney G, Sherard BD, eds. Cheyenne, WY: Wyoming Department of Health; 2008.
This report aggregates data on adverse events from July 2007 to June 2008 and analyzes the results of data collected in the 3 years since the Wyoming reporting program began.
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.
Journal Article > Commentary
The CMS ruling on venous thromboembolism after total knee or hip arthroplasty: weighing risks and benefits.
Streiff MB, Haut ER. JAMA. 2009;301:1063-1065.
This commentary addresses the Centers for Medicare and Medicaid Services' classification of venous thromboembolism as a never event.
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.
May H. Salt Lake Tribune. June 26, 2009.
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.