Narrow Results Clear All
- Communication Improvement 10
- Culture of Safety 10
- Education and Training 12
Error Reporting and Analysis
- Error Reporting 12
- Human Factors Engineering 2
- Legal and Policy Approaches
- Logistical Approaches 4
- Policies and Operations 1
- Quality Improvement Strategies 20
- Research Directions 3
- Teamwork 1
- Technologic Approaches 9
- Transparency and Accountability 1
- Diagnostic Errors 6
- Discontinuities, Gaps, and Hand-Off Problems 3
- Drug shortages 1
- Fatigue and Sleep Deprivation 1
- Identification Errors 1
- Medical Complications 6
- Medication Safety 9
- Overtreatment 1
- Psychological and Social Complications 4
- Surgical Complications 6
- Family Members and Caregivers 2
- Health Care Executives and Administrators 46
Health Care Providers
- Nurses 2
- Non-Health Care Professionals 34
- Patients 10
Search results for "Health Care Providers"
Manchester, UK: General Medical Council; June 2019.
Finding the appropriate balance between assigning criminality and accountability for tragic preventable patient harm is difficult. Summarizing a high-profile case in the United Kingdom that involved the death of a pediatric patient, misdiagnosis, and a senior pediatric trainee, this report explores elements of the criminality and accountability debate across the system and discusses policy, judicial, and individual components of a fair and just response to adverse events to keep organizations, clinicians, and patients safe.
Organisation for Economic Co-operation and Development. Paris, France: OECD Publishing; 2019. ISBN: 978926474260.
The overprescribing of prescription opioids heightens the likelihood of opioid dependence and harm. This report shares data from 25 countries to provide a baseline for the current crisis. The publication illustrates the complexity of the opioid epidemic and suggests that system-focused multisector strategies are required to address the problem.
Patient Safety Ethics: How Vigilance, Mindfulness, Compliance, and Humility can Make Healthcare Safer.
Banja JD. Baltimore, MD: Johns Hopkins University Press; 2019. ISBN: 9781421429083.
Canadian Patient Safety Institute and Health Standards Organization.
This draft 5-year framework aims to guide the activities in Canada to focus action, resources, and policy development on supporting care improvement. The document is structured around five goals: people-centered care, safe care, accessible care, appropriate care, and continuous care. The authors invited Canadian patients, families, clinicians, organization leaders, and policymakers to provide input on the material to ensure its applicability across the country.
London, UK: Royal College of Surgeons of England; 2019.
Introducing innovations in practice involves taking calculated risks. To ensure patient safety, new techniques should be accompanied by training, oversight, and heightened awareness of the learning curve. This book provides a framework to guide the design and introduction of new surgical procedures into regular practice. It includes recommendations for auditing, cost assessment, and effectiveness review.
AHRQ National Scorecard on Hospital-Acquired Conditions Updated Baseline Rates and Preliminary Results 2014–2017.
Rockville, MD: Agency for Healthcare Research and Quality; January 2019.
Hospital-acquired conditions (HACs) represent a significant source of preventable harm to patients. The Centers for Medicare and Medicaid Services financially penalizes hospitals with increased numbers of HACs through the Hospital-Acquired Condition Reduction Program. This policy of nonpayment has prompted hospitals to focus significant resources on preventing HACs. This AHRQ report found a reduction in HACs from 99 per 1000 acute care discharges to 86 per 1000 discharges between 2014 and 2017, representing a decrease in 910,000 HACs and savings of $7.7 billion. Declines in certain HACs such as adverse drug events and Clostridium difficile infections were noted to be more significant as compared to others. A past WebM&M commentary highlighted the clinical significance of HACs and described an incident involving a patient who developed a pressure ulcer while in the hospital.
Williams N. Department of Health and Social Care. London, England: Crown Copyright; 2018.
Accountability for errors and organizational assessment of failures affect incident reporting. This policy review explores how potential legal ramifications stemming from investigations of negligence can hinder improvement efforts and outlines recommendations to support safety culture in health care.
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.
Battles J, Azam I, Grady M, Reback K, eds. Rockville, MD: Agency for Healthcare Research and Quality; 2017. AHRQ Publication No. 17-0017-EF.
This publication describes the results of demonstration projects funded by AHRQ's Patient Safety and Medical Liability Reform Initiative. Included studies examined communication and resolution programs, patient reporting of adverse events, and patient perceptions of error disclosure. An overarching theme of these studies is the gap between recommended communication practices and usual clinical care and communication. Several studies demonstrated challenges of implementing health system interventions to improve safety across a range of interventions, including error disclosure training, shared decision-making, and medication safety during transitions in care. These studies reveal the importance of measuring and improving safety culture as a foundation for patient safety efforts. Commentaries by various patient safety experts highlight the need for ongoing support for research at the intersection of patient safety and medical liability. A past PSNet perspective described how evidence-based improvements to the medical liability system could influence accountability and compensation for errors.
Philadelphia, PA: Pew Charitable Trusts and Institute for Behavioral Health, Heller School for Social Policy and Management at Brandeis University; 2016.
Drug monitoring systems can help track opioid prescription activity to mitigate the opioid crisis. Highlighting the value of these state-sponsored programs to reduce overprescribing, this report recommends eight practices to optimize the use of prescription drug monitoring programs and review state adoption of them. The strategies include simplifying the prescriber enrollment process and integrating health information technology.
Allegranzi B, Bischoff P, de Jonge S, et al; WHO Guidelines Development Group. Geneva, Switzerland: World Health Organization; 2016. ISBN: 9789241549882.
Efforts to reduce surgical site infections have achieved some success. The World Health Organization has taken a leading role in eliminating health care–associated harms and has compiled guidelines to address factors that contribute to surgical site infections in preoperative, intraoperative, and postoperative care. The document includes recommendations for improvement informed by the latest evidence.
Chicago, IL: American Board of Medical Specialties; 2016.
In response to the 2015 Improving Diagnosis in Health Care report, the National Patient Safety Foundation and American Board of Medical Specialties convened a multidisciplinary panel of patient safety experts to determine safety challenges in the diagnostic process as a way to inform recommendations for improving diagnosis. Their consensus focused on educational, assessment, and cultural aspects of the process.
Cambridge, MA: CRICO Strategies; 2016.
Communication failures are known to contribute to medical errors. Analyzing more than 7000 cases in which communication breakdowns led to patient harm, this report explores selected specialties where such failures occur and discusses opportunities to improve information sharing among health care providers.
Washington, DC: United States Government Accountability Office; January 5, 2016. Publication GAO-16-158.
The Veterans Health Administration faces various challenges to providing safe care, including poor continuity during transitions to different locations which can result in inappropriate discontinuation of medications that patients require. This government report discuses efforts to reduce gaps in medication access and suggests developing clear policies to prevent patient harm in this population.
Hoffman J, ed. Cambridge, MA: CRICO Strategies; 2014.
This analysis of more than 4700 diagnosis-related malpractice claims found that most errors occur in the ambulatory setting, involve lapses in clinical judgement, and result in missed diagnosis of cancer. The authors use the data to explore cognitive and process failures that contributed to diagnostic errors.
Drug Shortages: Public Health Threat Continues, Despite Efforts to Help Ensure Product Availability.
Washington, DC: United States Government Accountability Office; February 10, 2014. Publication GAO-14-194.
Harrow, Middlesex, UK: The Patients Association; 2013.
This publication provides patient and family accounts of incidents involving inadequate care or harm and highlights the need for improvements recommended in a National Health Services report.
Patient Safety: HHS Has Taken Steps to Address Unsafe Injection Practices, but More Action Is Needed.
Kohn LT. Washington, DC: United States Government Accountability Office; July 2012. Publication GAO-12-712.
Poll: Many Sick Americans Experience Significant Financial Problems and Report Their Care is not Well-Managed.
Princeton, NJ: Robert Wood Johnson Foundation, National Public Radio, and the Harvard School of Public Health. May 21, 2012.
This report describes findings from a poll that investigated how cost of care and health insurance affect patients' experiences of health care quality and safety in the United States.
Ruoff G, ed. Cambridge, MA: CRICO Strategies; 2012.
This report analyzes malpractice claims from 90 hospitals across the United States to identify risks in emergency medicine.