Narrow Results Clear All
- Communication Improvement 3
- Culture of Safety 2
- Education and Training 3
- Error Reporting and Analysis
- Human Factors Engineering 6
- Legal and Policy Approaches 6
- Logistical Approaches 2
- Quality Improvement Strategies 5
- Specialization of Care 4
- Clinical Information Systems 8
- Diagnostic Errors 3
- Discontinuities, Gaps, and Hand-Off Problems 2
- Fatigue and Sleep Deprivation 1
- Identification Errors 2
- Medical Complications
- Medication Safety 10
- Psychological and Social Complications 1
- Surgical Complications 4
- Transfusion Complications 1
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
Shaw R, Drever F, Hughes H, Osborn S, Williams S. Qual Saf Health Care. 2005;14:279-283.
This study evaluated the utility of a voluntary reporting system from several National Health Service trusts. Investigators collected, categorized, and analyzed anonymized data from nearly 29,000 incidents, with the largest proportion related to falls. Discussion includes detailed presentation of the frequency of events, their location of occurrence, and the low rate of incidents associated with a catastrophic outcome. The authors conclude that this type of reporting system can provide useful information on a national level but requires the development of information technology systems to support the efforts.
Journal Article > Study
Milch CE, Salem DN, Pauker SG, Lundquist TG, Kumar S, Chen J. J Gen Intern Med. 2006;21:165-170.
This descriptive study analyzed nearly 100,000 reports from 26 acute care hospitals with investigators discovering wide variations in reporting rates across sites. The most common classification included medication-related events, and more than half of all events affected a patient before being caught. The authors report that nurses were the most frequent users of the electronic reporting systems, whereas physicians accounted for an overwhelming minority. A past study found similar underuse of reporting systems by physicians and recommended alternative methods for capturing physician-based information about adverse events.
Newsweek. October 16, 2006:44-68, 72.
This "Health for Life" series features 10 case studies about patient safety and quality improvement efforts as well as several short articles on safety-related topics such as disclosure and computerizing medical care.
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.
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.
Carter M. Seattle Times. March 9, 2007:A1.
This article investigates and reports on the prevalence of medical errors in a county jail system in Washington.
Special or Theme Issue
Pediatr Crit Care Med. 2007;8(suppl):S1-S43.
This supplement covers issues related to safety indicators, fatigue, electronic medical records, infection, and disclosure of medical errors in the care of critically ill children.
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.
Journal Article > Study
Levtzion-Korach O, Alcalai H, Orav EJ, et al. J Patient Saf. 2009;5:9-15.
The limitations of standard incident reporting systems have been well documented. Although ubiquitous and relatively easy to use, such systems detect only a fraction of adverse events, are underused by physicians, and yield data that often are not analyzed or disseminated promptly. This analysis of data from a commercial, web-based system at an academic hospital confirms some prior concerns, but the authors were able to demonstrate that rapid review of reports resulted in specific system changes to improve workflow and safety. A prior article presented a framework for using incident reporting data to improve patient safety.
May H. Salt Lake Tribune. June 26, 2009.
Legislation/Regulation > Government Resource
Council recommendation on patient safety, including the prevention and control of healthcare associated infections.
Council of the European Union (2009).
This document provides a series of suggestions to improve patient safety in health care systems across the European Union.
Opportunities and Recommendations for State–Federal Coordination to Improve Health System Performance: A Focus on Patient Safety.
Buxbaum J. Portland, ME: National Academy for State Health Policy; January 2010.
This briefing summarizes recommendations from a roundtable of health policy leaders, who selected the following areas as foci for initial federal–state coordination of safety efforts: reducing health care–associated infections, decreasing preventable hospital readmissions, and minimizing hospitalization for ambulatory conditions.
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.
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.