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- WebM&M Cases 1
- Perspectives on Safety 8
- Commentary 19
- Review 3
- Study 20
- Book/Report 12
- Legislation/Regulation 2
- Newspaper/Magazine Article 16
- Special or Theme Issue 1
- Web Resource 6
- Award 2
- Grant 2
- Press Release/Announcement 2
- Communication Improvement 8
- Culture of Safety 5
Education and Training
- Students 1
Error Reporting and Analysis
- Error Reporting 24
- Human Factors Engineering 4
Legal and Policy Approaches
- Regulation 23
- Logistical Approaches 2
- Quality Improvement Strategies 17
- Research Directions 1
- Teamwork 5
- Clinical Information Systems 9
- Transparency and Accountability 2
- Alert fatigue 1
- Device-related Complications 1
- Diagnostic Errors 3
- Discontinuities, Gaps, and Hand-Off Problems 3
- Fatigue and Sleep Deprivation 1
- Identification Errors 1
- Medical Complications 23
- Medication Errors/Preventable Adverse Drug Events 4
- Psychological and Social Complications 1
- Surgical Complications 13
- Transfusion Complications 1
- Internal Medicine 32
- Nursing 1
- Pharmacy 1
- Health Care Executives and Administrators 71
Health Care Providers
- Nurses 1
Non-Health Care Professionals
- Media 2
- Patients 14
- Asia 1
- Australia and New Zealand 2
- Europe 3
- Canada 2
Search results for "Incentives"
- Policy Makers
Journal Article > Study
Fukuda H, Imanaka Y, Hirose M, Hayashida K. Health Policy. 2008;89:26-36.
In this Japanese study, larger and more profitable hospitals were able to devote more resources to patient safety and infection control efforts.
O'Reilly KB. American Medical News. May 12, 2008.
This article reports that the Centers for Medicare and Medicaid Services (CMS) has proposed expanding the list of hospital-acquired conditions that it will no longer cover.
Fuhrmans V. Wall Street Journal. January 15, 2008:D1.
This article reports on health insurance companies adopting the tactic of not paying for preventable errors, which parallels a similar federal decision.
Journal Article > Study
Who pays for medical errors? An analysis of adverse event costs, the medical liability system, and incentives for patient safety improvement.
Mello MM, Studdert DM, Thomas EJ, Yoon CS, Brennan TA. J Empirical Leg Stud. 2007;4:835–860.
Organizational costs associated with medical errors, and specifically adverse drug events, have been reported. This study analyzes such costs and also examines what proportion is absorbed by hospitals. Using claims data from a past study, investigators determined that hospitals assumed only 22% of costs associated with injuries. The authors advocate for continued efforts to improve the business case for safety interventions, partly by understanding the marginal costs associated with a given safety improvement. Legal reforms or market interventions are also suggested as mechanisms to deal with the externalization of injury costs.
Lerner M. Star Tribune. September 18, 2007;News section:5B.
This article reports on Minnesota's adoption of a policy for hospitals to not charge patients or insurers for never events or consequent treatment.
Kowalczyk L. Boston Globe. September 17, 2007;Metro section:1A.
This article reports on how numerous Massachusetts hospitals have implemented policies to waive charges for the set of serious errors categorized as never events.
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.
Shea KK, Shih A, Davis K. New York, NY: The Commonwealth Fund; July 2007.
This report discusses results of a national survey regarding how to improve the safety and quality of health care. Respondents supported greater adoption of health information technology, public reporting of performance on quality measures, and more oversight.
Collins LM. Deseret Morning News. July 8, 2007;A1.
This article reports on Utah health officials' recent efforts to mandate error reporting, make that information open to the public, and use the data to improve patient safety.
Journal Article > Commentary
Vemula R, Assaf RR, Al-Assaf AF. J Healthc Qual. 2007;29:6-10.
The authors discuss strategies to make the Patient Safety and Quality Improvement Act of 2005 succeed, including the use of incentives, continuing education, and residency program reform.
Smerd J. Workforce Management. June 11, 2007;1, 16-19.
This article discusses the financial impact on employers when an employee is affected by medical error.
Legislation/Regulation > New Jersey Legislation
New Jersey Legislature. A4327 (2007).
This bill amends a previous law by requiring that serious preventable adverse events be reported to the New Jersey Department of Health and Senior Services and that a list of these errors and where they occurred be publicly available.
Perspectives on Safety > Perspective
with commentary by Jill Rosenthal, MPH, State Error Reporting Systems, June 2007
Seven years ago, the Institute of Medicine (IOM) called on states to create mandatory reporting systems as part of a strategy to identify and learn about medical errors and ultimately to improve patient safety. Since then, many states have responded by creating or improving reporting systems to collect information about hospital-based adverse events. These systems can provide states with an opportunity to strengthen their facility oversight functions, safeguard the public, and partner with providers to improve health care quality.
Perspectives on Safety > Interview
State Error Reporting Systems, June 2007
Diane Rydrych, MA, is Assistant Director of the Division of Health Policy at the Minnesota Department of Health, where she oversees their successful and influential adverse health events reporting system. We asked her to speak with us about the Minnesota initiative and some of the broader lessons for state error reporting systems.
Perspectives on Safety > Interview
International Perspectives on Safety, May 2007
Sir Liam Donaldson, MD, MSc, is England's Chief Medical Officer, a post often referred to as "the Nation's Doctor" (similar to the role of the U.S. Surgeon General). Trained as a surgeon, Sir Liam has been an inspirational leader in public health and health care quality in the United Kingdom for two decades. He has also emerged as a world leader in the patient safety field, authoring or commissioning dozens of influential reports, and serving as the founding chair of the World Health Organization's World Alliance for Patient Safety. We spoke to him about patient safety from an international perspective.
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.
Cases & Commentaries
- Spotlight Case
- Web M&M
Peter Lindenauer, MD, MSc; November 2006
A woman with end stage renal disease and heart disease on anticoagulation receives a pneumonia vaccination that causes a large hematoma.
The Commonwealth Fund Commission on a High Performance Health System. New York, NY: The Commonwealth Fund; August 2006.
This report calls for providing "safe, well-coordinated, accessible, and efficient" care through five key steps: expanding health insurance coverage, implementing evidence-based patient safety and quality interventions, increasing use of health information technology, public reporting of safety and quality measures, and rewarding achievement in quality through "pay-for-performance." The authors ascribe the current quality problems in the U.S. health care system to system failures, including misaligned payment incentives, inadequate motivation to challenge the status quo, inadequate information systems, duplicative regulatory systems, and an overemphasis on autonomy.
Journal Article > Study
McCarthy D, Blumenthal D. Milbank Q. 2006;84:165-200.
This study shares the efforts of six different health care organizations in implementing interventions to improve patient safety. All of the organizations identified culture change as the most important factor in promoting safety, though the mechanisms to achieve such change differed. The authors provide a contextual background of safety culture, including definitions, attributes, and strategies to approach the issue, and present a detailed account of each case study. They point out that creating a desired culture of safety may be both foundational to safety efforts and also very challenging to accomplish. The shared stories offer a practical perspective regarding the issues that face most organizations committed to improving patient safety.
Edmonton, AB: Canadian Patient Safety Institute; December 2, 2005.
This news release announces the selection of 28 research and demonstration projects eligible for funding from the Canadian Patient Safety Institute research initiative.