Narrow Results Clear All
- Communication Improvement 2
- Culture of Safety 1
- Education and Training 3
- Error Reporting and Analysis 9
- Legal and Policy Approaches
- Quality Improvement Strategies 5
- Teamwork 1
- Technologic Approaches 5
- Identification Errors 1
- Medical Complications 5
- Medication Safety 3
- Psychological and Social Complications 1
- Surgical Complications 3
- Transfusion Complications 1
Search results for "Incentives"
Hall M, McCue MJ. New York, NY: The Commonwealth Fund; March 22, 2013.
This report found that insurance companies spend on average $2.94 per member toward patient safety improvement, about 10% of the total quality improvement expense.
Oakbrook Terrace, IL: The Joint Commission; January 2010.
America's hospitals continued to improve the quality of care they provide for myocardial infarction, congestive heart failure, pneumonia, and surgical care, according to the newest report from The Joint Commission. Compared to the prior report published in 2007, hospitals increased their provision of evidence-based treatments across all four disease processes. In particular, significant improvements were achieved in use of measures to prevent surgical site infections. While the prior report provided data on adherence to the National Patient Safety Goals, these measures were not discussed in the current report.
Opportunities and Recommendations for State–Federal Coordination to Improve Health System Performance: A Focus on Patient Safety.
Buxbaum J. Portland, ME: National Academy for State Health Policy; January 2010.
This briefing summarizes recommendations from a roundtable of health policy leaders, who selected the following areas as foci for initial federal–state coordination of safety efforts: reducing health care–associated infections, decreasing preventable hospital readmissions, and minimizing hospitalization for ambulatory conditions.
Wright S. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; January 5, 2010. Report No. OEI-06-09-00360.
Rockville, MD; Agency for Healthcare Research and Quality; November 2009. AHRQ Publication No. 09(10)-0084.
This publication highlights AHRQ's patient safety research efforts in the 10 years since the Institute of Medicine report, To Err Is Human, was published.
Golden, CO: HealthGrades, Inc.; April 2009.
This analysis of patient safety in Medicare patients from 2005–2007 concludes that while modest improvements have been made, patient safety incidents still account for nearly 100,000 preventable deaths and nearly $7 billion in excess costs yearly. The report also recognizes the best performing hospitals with a "Patient Safety Excellence Award"—hospitals scoring in the top 15% according to a ranking methodology developed by the authors. As with prior HealthGrades reports, the study uses the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSIs) to measure the incidence of patient safety problems and compare hospitals. The limitations of using PSIs as a performance measure have been discussed in a prior study and AHRQ WebM&M commentary, and it is important to note that this report did not undergo external peer review.
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.
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; December 2008. Report No. OEI-06-07-00470.
The Tax Relief and Health Care Act of 2006 mandated that the Office of Inspector General (OIG) report to Congress the incidence of "never events" among Medicare beneficiaries, payment by Medicare for services in connection with such events, and the process used to identify events and deny payments. This report addresses that mandate by providing a descriptive analysis of the key issues to understanding hospital-based adverse events. The report is focused around discussion of seven critical issues that are explored in detail. Of note, OIG expanded the study of never events to the broader topic of adverse events in their analysis.
Farley DO, Damberg CL, Ridgely MS, et al. Santa Monica, CA: RAND Corporation; 2008. ISBN: 9780833044808
This report analyzes AHRQ's patient safety activities, synthesizes results of the full RAND evaluation, and discusses the knowledge generated by funded research projects as well as how these have contributed to improvement.
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.
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.
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.