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- Communication Improvement 1
- Education and Training 1
- Error Reporting and Analysis
- Human Factors Engineering 2
- Legal and Policy Approaches
- Quality Improvement Strategies 2
- Identification Errors 2
- Medical Complications 1
- Medication Safety
- Psychological and Social Complications 1
- Surgical Complications 2
Search results for "Error Reporting and Analysis"
Valencia MJ. Boston Globe. March 10, 2011.
This newspaper article reports on a fatal medication error involving an anticoagulant overdose.
Journal Article > Study
Litigation related to drug errors in anaesthesia: an analysis of claims against the NHS in England 1995-2007.
Cranshaw J, Gupta KJ, Cook TM. Anaesthesia. 2009;64:1317-1323.
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 > Study
Public reporting of antibiotic timing in patients with pneumonia: lessons from a flawed performance measure.
Wachter RM, Flanders SA, Fee C, Pronovost PJ. Ann Intern Med. 2008;149:29-32.
Efforts to improve the quality and safety of care are being driven in part by a growing focus on public reporting. This commentary shares the potential for the unintended consequences of reporting on flawed performance measures, using time to first antibiotic dose (TFAD) in patients with pneumonia as an example. The authors discuss the background data for this particular quality measure, how it was translated into a performance standard, and the response it generated from emergency departments as well as payers, regulators, and professional societies. The authors conclude with a number of lessons learned from this case example, including the tension that results from having providers balance their desire to do the right thing with the public's view of their quality of care when they are in conflict with each other. A past AHRQ WebM&M commentary discussed the unintended consequences of achieving a good report card on such measures.
Cases & Commentaries
- Web M&M
Albert W. Wu, MD, MPH; Peter J. Pronovost, MD, PhD; January 2004
A patient receiving end-of-life care, whose code status was DNR, encounters a potentially life-threatening medication error.