Narrow Results Clear All
- Communication Improvement 29
- Culture of Safety 31
Education and Training
- Students 1
Error Reporting and Analysis
- Error Reporting 25
- Human Factors Engineering 11
- Legal and Policy Approaches 24
- Logistical Approaches 5
- Policies and Operations 1
- Quality Improvement Strategies 42
- Research Directions 1
- Specialization of Care 5
- Teamwork 9
- Technologic Approaches 22
- Transparency and Accountability 1
- Device-related Complications 5
- Diagnostic Errors 2
- Discontinuities, Gaps, and Hand-Off Problems 6
- Identification Errors 3
- Interruptions and distractions 1
- Medical Complications 9
- Medication Errors/Preventable Adverse Drug Events 8
- Nonsurgical Procedural Complications 1
- Overtreatment 1
- Psychological and Social Complications 7
- Surgical Complications 8
- Internal Medicine 6
- Surgery 5
- Nursing 8
- Pharmacy 9
- Family Members and Caregivers 1
- Health Care Executives and Administrators 98
Health Care Providers
- Nurses 10
- Physicians 10
- Non-Health Care Professionals 61
- Patients 33
- United States of America
Search results for "United States of America"
- United States of America
Joint Commission and the American Nurses Association. Oakbrook, IL: Joint Commission Resources, Inc; 2018. ISBN: 9781635850611.
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.
Dallas, TX: Facilities Guidelines Institute; 2018.
These updated guidelines include design changes, such as the adoption of private rooms to reduce medical error, interruptions, and hospital-acquired infections. The 2018 edition was developed as a 3-volume set covering hospitals, outpatient facilities, and residential health, care, and support facilities. Each provides information on design elements that enhance safety. The material also includes risk assessments to identify space concerns that could lead to unsafe conditions.
Weick KE, Sutcliffe KM. San Francisco, CA: John Wiley & Sons; 2015. ISBN: 9781118862414.
According to Weick and Sutcliffe, high-reliability organizations operate under challenging conditions yet experience fewer problems than would be anticipated as they have developed ways of "managing the unexpected" better than most organizations. The authors, professors at the University of Michigan School of Business, use both case studies and theory-based analysis to explain the methods that result in organizational mindfulness, and, through it, a more robust culture of safety. This third edition of their classic text provides individual chapters on each of the five elements of high reliability and pays increased attention to the roles of interaction, sensemaking, and language in achieving more reliable performance under risky conditions.
Youngberg BJ, ed. Jones & Bartlett Learning: Sudbuery MA; 2013. ISBN: 9780763774042.
This revised edition of a comprehensive resource on patient safety includes new chapters discussing such topics as the complexity of defining error and the need for medical and nursing education to develop leadership skills to help drive improvement efforts.
Rozovsky FA, Woods JR Jr, eds. San Francisco, CA: Jossey Bass; 2011. ISBN: 9781118086995.
This well-referenced and up-to-date handbook covers many of the regulatory and operational issues relevant to developing an organizational patient safety program. It is particularly strong in the areas of regulatory compliance, error reporting, and disclosure. Patient safety officers and risk managers are likely to find it of considerable interest.
Gosbee JW, Gosbee LL, eds. Oakbrook Terrace, IL: Joint Commission Resources; 2010. ISBN: 9781599404110.
This book provides a general introduction to human factors engineering and uses case studies to illustrate its importance as a tool for improving safety.
Oakbrook Terrace, IL: Joint Commission Resources and the American Society of Health-System Pharmacists; 2009. ISBN: 9781599403090.
This book provides background on the medication reconciliation process and tips for its application, along with sample forms, checklists, and case studies.
Langley GJ, Moen R, Nolan KM, Nolan TW, Norman CL, Provost LP. San Francisco, CA: Jossey-Bass; 2009. ISBN: 9780470192412.
Effective integration of improvement initiatives are required for these efforts to succeed. The authors take Deming's "Plan Do Study Act" premise and provide demonstrations of rapid improvement initiatives with stories from business, law, and health care to illustrate the successes of this approach since the publication of the first edition in 1996. Applicable tools and practical ideas couch the concepts in concrete experience. A resource guide to change concepts completes the book.
McDermott RE, Mikulak RJ, Beauregard MR. New York, NY: Productivity Press: Routledge; 2009. ISBN: 9781563273773.
The authors provide a handbook that serves as the core tool for understanding and implementing the failure mode and effect analysis (FMEA) process. Written for use as a training and project tool, the handbook contains chapters that introduce the concept of FMEA and its history as a process safety tool in the aerospace and automotive industries. FMEA provided a standard language that allowed the tool to be used by technical and administrative employees at all levels to learn about opportunities for failure during the course of the work they do. The ten steps of a FMEA, case studies where they have been used, and a discussion of where and when to use FMEAs provide practical information for a variety of audiences interested in proactive risk assessment.
Reinertsen JL, Bisognano M, Pugh MD. 2nd ed. Cambridge, MA: Institute for Healthcare Improvement; 2008.
This white paper describes seven leverage points leaders can use to drive organizational change initiatives for safety and quality. The authors apply this theoretical framework to IHI's 100,000 Lives Campaign, provide a self-assessment tool, and draw from their experience since the 2005 edition.
Gawande A. New York, NY: Metropolitan Books; 2007. ISBN: 0805082115.
Golden, CO: HealthGrades, Inc.; April 2007.
This fourth annual report on the safety of hospitalized Medicare patients builds on past efforts to evaluate hospital performance. The report uses the Agency for Healthcare Research and Quality's Patient Safety Indicators to provide benchmarks for such performance, identify current trends in safety issues, and estimate preventable events nationally. The report suggests that the patient safety incidents captured account for nearly $9 billion in excess cost during 2003-2005, and nearly 250,000 potentially preventable deaths occurred during the same time period. Grading for all states and a selected group of highly rated hospitals is included with the implication that, if all hospitals performed at a level comparable to the ones acknowledged, more than 34,000 Medicare deaths could be avoided with a cost savings of $1.74 million. As with the second and third annual reports, several methodological limitations exist, and the reports themselves did not receive external peer review.
Oakbrook Terrace, IL: The Joint Commission; March 2007.
This report reveals that the overall quality of care delivered by US hospitals improved steadily between 2003 and 2005, as measured by adherence to evidence-based treatments for myocardial infarction, congestive heart failure, and pneumonia. Adherence to the Joint Commission's National Patient Safety Goals, which include measures to prevent wrong-site surgery and promote medication reconciliation, was also measured. Although results on these measures showed a more mixed picture, the report cautions that changes in measurement during the study period limit interpretability of the results.
Medmarx Data Report: A Chartbook of Medication Error Findings from the Perioperative Settings from 1998-2005.
Rockville, MD: United States Pharmacopeia; 2007.
This report shares findings from analysis of more than 11,000 perioperative medication errors reported through Medmarx and includes recommendations to avoid these types of errors.
National Quality Forum. Washington, DC: National Quality Forum; 2007.
The National Quality Forum used expert consensus and evidence review to identify 30 health care ''safe practices'' that should be consistently utilized to minimize the risk of harm to patients. Originally disseminated in 2003 and updated in 2006, these practices are organized into seven primary content areas: creating a culture of safety, matching health care needs with service delivery capability, facilitating information transfer and clear communication, preventing healthcare-associated infections, honoring patient wishes for informed content and disclosure, increasing safe medication use, and adopting safe practices in specific clinical care settings or for specific processes of care. Each practice is presented in capsule form with detailed specifications, applicable setting of care, supporting evidence, and additional background.
Oakbrook Terrace, IL: The Joint Commission; 2007.
Low health literacy is a recognized patient safety problem. Prior research has demonstrated that patients with impaired health literacy have difficulty comprehending prescription instructions and warnings. This Joint Commission report, developed by an expert panel, contains specific recommendations for improving provider–patient communication, in order to ameliorate the problem of low health literacy as much as possible. The report recommends that organizations establish communication as a patient safety priority and calls for financial support for patient-centered care initiatives.
The Medication Errors Panel. Sacramento, CA: California State Senate; March 2007.
This report shares findings from an expert panel convened to study the causes of medication error in the outpatient setting and provide recommendations for reducing errors associated with prescription and over-the-counter medications.
St. Paul, MN: Minnesota Department of Health; January 2009.
This report provides background on the Minnesota Never Events reporting initiative, tips for patients on how to receive the safest care possible, and a table of events reported by all hospitals in the state.
Geller ES, Johnson D. Virginia Beach, VA: Coastal Training Technologies; 2007. ISBN: 096640413.
The authors discuss how to increase staff safety awareness by developing four skills: acting, coaching, thinking, and seeing.