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Search results for "Government Resource"
Washington, DC: Department of Veterans Affairs, Office of Inspector General. August 22, 2019. Report No. 19-07429-195.
Hospitalized patient suicide is a sentinel event. This report describes an investigation into a patient suicide incident in the Veterans Affairs health system that found numerous conditions that contributed to the event, such as nonoperational security cameras, ineffective rounding policy, and lack of leadership knowledge of safety practices in mental health units. Recommendations for improvement include staff education, standardization of rounding, and robust oversight of frontline practice.
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.
Boston, MA: Betsy Lehman Center for Patient Safety and Medical Error Reduction; 2016.
Web Resource > Government Resource
Centers for Medicare & Medicaid Services.
The Centers for Medicare and Medicaid Services (CMS) provides consumers with publicly available information on the quality of Medicare-certified hospital care through this Web site. The site includes specific information for both patients and hospitals on how to use the data to guide decision-making and improvement initiatives. Most recently, listings from the Hospital-Acquired Condition Reduction Program (HACRP) and data on Department of Veterans Affairs hospitals were added to the reports available.
Salt Lake City, UT: Utah Department of Health, Utah Hospitals & Health Systems Association, and HealthInsight; March 10, 2010.
This brief provides information on 101 sentinel events reported to the state of Utah in 2009. The report also includes background on efforts to address such incidents.