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Search results for "Book/Report"
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.
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.
East Perth, WA, Australia: Department of Health of Western Australia; 2006.
This report shares the 2005-2006 results of Western Australia's sentinel event reporting program and documents a reduction in two types of events: wrong site/wrong part surgeries and retained foreign objects.