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Approach to Improving Safety
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Press Release/Announcement
Eliminating Serious, Preventable, and Costly Medical Errors - Never Events.
Baltimore, MD: Centers for Medicare & Medicaid Services (CMS) Office of Public Affairs; May 18, 2006.
This fact sheet provides information regarding the Centers for Medicare and Medicaid Services' initiative to better understand and minimize never events.
Journal Article > Commentary
Patient safety: disclosure of medical errors and risk mitigation.
Moffatt-Bruce SD, Ferdinand FD, Fann JI. Ann Thorac Surg. 2016;102:358-362.
Although error disclosure is increasingly encouraged in health care, challenges to achieving transparency include liability and risk considerations, particularly for surgeons. This commentary describes the experiences of two health care systems that have implemented approaches to support transparent disclosure of medical errors.
Award
Patient safety teams recognised at BMJ awards.
London, UK: Health Foundation. May 9, 2014.
The Great Ormond Street Hospital Foundation NHS Trust received the 2014 Berwick Patient Safety Team Award for their project "Pursuing Zero by Building Sustainable Foundations for Safety," which applied recommendations generated in response to the Francis report. The program introduced a daily questionnaire for parents and patients about problems related to medication errors, equipment, communication, or organization of care, which was then reviewed with a nurse to immediately address concerns.
Journal Article > Review
Interventions to improve safe and effective medicines use by consumers: an overview of systematic reviews.
Ryan R, Santesso N, Lowe D, et al. Cochrane Database Syst Rev. 2014;4:CD007768.
This review describes how researchers identified and analyzed systematic reviews on interventions to augment safe medication use. The authors provide an overview of safety improvement strategies, such as reminders and financial incentives. Medication self-management programs generally enhanced medication safety and health outcomes, but more research is needed for clinically complex populations and technology-enabled strategies.
Award
The 2013 John M. Eisenberg Patient Safety and Quality Awards.
Jt Comm J Qual Patient Saf. 2014;40:195-218.
Articles in this special issue highlight the achievements of the 2013 John M. Eisenberg Patient Safety and Quality Award honorees. The projects include a discharge handoff tool, a surgical briefing and debriefing, and a statewide campaign to reduce preventable readmissions.
Journal Article > Commentary
Implementing the Safety Thermometer tool in one NHS trust.
Buckley C, Cooney K, Sills E, Sullivan E. Br J Nurs. 2014;23:268-272.
This commentary details a National Health Service trust's experience implementing a patient safety measurement tool that incentivized improvement in four areas: falls, pressure ulcers, venous thromboembolisms, and catheter-associated urinary tract infections.
Journal Article > Study
Engaging residents and fellows to improve institution-wide quality: the first six years of a novel financial incentive program.
Vidyarthi AR, Green AL, Rosenbluth G, Baron RB. Acad Med. 2014;89:460-468.
This retrospective study found that providing resident and fellow physicians with a financial incentive to meet inpatient quality improvement goals led to enhanced patient safety processes, such as hospital-to-home transitions and timely completion of discharge summaries. These findings highlight a need for broader implementation of trainee incentives as part of quality improvement.
Cases & Commentaries
More Treatment—Better Care?
- Web M&M
Rita Redberg, MD, MSc; December 2011
A patient with Guillain-Barré syndrome received more than the recommended number of plasmapheresis treatments. When the ordering physicians were asked why so many treatments were given, they both responded that the patient was improving so they felt that more treatments would help him recover even more.
Newspaper/Magazine Article
Revealing their medical errors: why three doctors went public.
O'Reilly KB. American Medical News. August 15, 2011.
This news article reports on health care providers who have publicly revealed direct involvement in cases of medical errors, with a goal of encouraging open disclosure, encouraging safety checks, and improving patient safety.
Newspaper/Magazine Article
First do no harm.
Allen M. Washington Monthly. March/April 2011.
This magazine article reports on medical errors in the United States health care system and discusses transparency as a tactic to improve patient safety.
Journal Article > Review
Hospital do-not-resuscitate orders: why they have failed and how to fix them.
Yuen JK, Reid MC, Fetters MD. J Gen Intern Med. 2011;26:791-797.
The review reveals shortcomings associated with do-not-resuscitate orders and suggests strategies to improve communication and hospital culture.
Newspaper/Magazine Article
A pinpoint beam strays invisibly, harming instead of healing.
Bogdanich W, Rebelo K. New York Times. December 28, 2010;A1.
This article explores inaccuracy of dosage, lack of protocol adherence, and absence of transparency as trends that hinder learning from radiological adverse events.
Newspaper/Magazine Article
Dennis Quaid's Quest.
Grant M. AARP The Magazine. September/October 2010;53:48-51,90-91.
This article highlights how a medication error inspired Dennis Quaid to promote patient safety and chronicles his efforts to reduce harm in health care.
Perspectives on Safety > Interview
In Conversation with... Charles Ornstein
The Role of the Media in Patient Safety, October 2009
Charles Ornstein is a senior reporter at ProPublica, a nonprofit news organization in New York. Formerly with the Los Angeles Times, he co-wrote a series of articles about medical errors at Martin Luther King Jr./Drew Medical Center, which closed in 2007; the series earned the newspaper a Pulitzer Prize for Public Service. He is also the president of the Association of Health Care Journalists. We asked him to speak with us about the role of the media in patient safety. This interview was conducted while he was still at the Times.
Newspaper/Magazine Article
Most surgery in wrong spot done on spine: 11 such cases found in state since 2006.
Smith S. Boston Globe. July 30, 2008;Metro section:1A.
This article reports on the incidence of wrong site surgeries in Massachusetts and describes complex factors that may contribute to such errors occurring in spinal surgery.
Newspaper/Magazine Article
Medicare says it won't cover hospital errors.
Pear R. New York Times. August 19, 2007.
This article reports on a new Centers for Medicare and Medicaid Services (CMS) rule mandating that Medicare will no longer pay for treating certain preventable errors starting in 2008, including some hospital-acquired infections, decubitus ulcers, and retained foreign bodies. The policy is generating considerable discussion in patient safety circles, with some expressing concerns regarding the economic impact on hospitals and the increased efforts it is likely to create for hospitals to document certain patient problems present at the time of admission.
Perspectives on Safety > Perspective
The Role of the Patient in Improving Patient Safety
with commentary by Rosemary Gibson, MSc, The Patient's Role in Safety, March 2007
Patients have three roles in improving patient safety: helping to ensure their own safety, working with health care organizations to improve safety at the organization and unit level, and advocating as citizens for public reporting and accountability of hospital and health system performance. The following case illustrates how patients can help ensure their own safety.
Audiovisual
Apology May Cut Medical Cost.
"The Early Show." CBS News Video. February 7, 2007.
This news video discusses the impact of apology on potential malpractice lawsuits and features a patient and her anesthesiologist discussing how apology helped them to overcome the psychological distress of medical error.
Newspaper/Magazine Article
Our long journey towards a safety-minded just culture. Part II: where we're going.
ISMP Medication Safety Alert! Acute Care Edition. September 21, 2006;11:1-2.
This second part of this series discusses the three types of behavior involved in error—human error, at-risk behavior, and reckless behavior—including causes of each and appropriate responses.