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Education and Training
- Students 1
- Error Reporting and Analysis 14
- Human Factors Engineering 2
- Legal and Policy Approaches
- Quality Improvement Strategies 5
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- Clinical Information Systems 4
- Transparency and Accountability 1
- Identification Errors 1
- Medical Complications 6
- Medication Safety 2
- Psychological and Social Complications 1
- Surgical Complications 5
Search results for "Incentives"
Journal Article > Commentary
Coiera E, Braithwaite J. Qual Saf Health Care 2009;18:99-103.
Efforts to improve patient safety have taken many forms, including accreditation, information technology, legislation, litigation, safety training, and systems change. Pay for performance (P4P) initiatives have also captured national attention as a mechanism to tie financial incentives to delivering high quality and safe care. This commentary expands on all of the drivers for change in the context of market forces, drawing on analogies from other industries. The authors discuss the design of a patient safety "market," measuring and putting a price on safety and establishing a safety baseline with targets. While pointing out the challenges and barriers involved, the authors describe how market forces can be an efficient and powerful driver of change in health care delivery.
Leape LL. Perspect Health Reform. New York, NY: The Commonwealth Fund; March 17, 2010.
Of three approaches to enhancing patient safety—regulation/accreditation, financial incentives, and public reporting—this perspective, written by the father of the modern patient safety movement, details how public reporting holds the most potential to stimulate improvement.
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.
Journal Article > Commentary
Bates DW, Wachter RM, Vanderveen T. Patient Saf Qual Healthc. July/August 2009;6:22-27.
This piece shares insights from an interactive audio conference regarding the potential impact of information technology on safe medication delivery.
Perspectives on Safety > Interview
The Business Case for Improving Safety, May 2009
The Business Case for Improving Safety
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.
Smith S. Boston Globe. June 19, 2008;Metro section:1B
Massachusetts government and state insurers have outlined policies whereby they will not reimburse hospitals for care related to 28 preventable errors, though they have not specified details about implementation or enforcement.
NY Medicaid ups the ante: by refusing to pay for 14 'never events,' the nation's biggest Medicaid program could propel other states into action.
DerGurahian J. Mod Healthc. June 16, 2008;38:6.
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.