Narrow Results Clear All
- Communication Improvement 28
- Culture of Safety 18
- Education and Training 8
Error Reporting and Analysis
- Never Events 21
- Error Reporting
- Human Factors Engineering 5
- Legal and Policy Approaches 28
- Logistical Approaches 2
- Policies and Operations 3
- Quality Improvement Strategies 33
- Research Directions 1
- Specialization of Care 2
- Teamwork 1
- Clinical Information Systems 5
- Transparency and Accountability 10
- Device-related Complications 6
- Diagnostic Errors 3
- Discontinuities, Gaps, and Hand-Off Problems 7
- Failure to rescue 1
- Fatigue and Sleep Deprivation 2
- Identification Errors 9
- Medical Complications 27
- Medication Errors/Preventable Adverse Drug Events 8
- Nonsurgical Procedural Complications 3
- Psychological and Social Complications 13
- Surgical Complications 16
- Allied Health Services 1
- Internal Medicine 39
- Surgery 5
- Nursing 2
- Pharmacy 3
- Family Members and Caregivers 4
- Health Care Executives and Administrators 118
Health Care Providers
- Nurses 1
- Physicians 11
Non-Health Care Professionals
- Media 2
- Patients 22
- Australia and New Zealand 3
- Europe 34
- Canada 6
United States of America
United States Federal Government
- Department of Health and Human Services (HHS) 24
- United States Federal Government 34
Search results for "Error Reporting"
- Error Reporting
Understanding the knowledge gaps in whistleblowing and speaking up in health care: narrative reviews of the research literature and formal inquiries, a legal analysis and stakeholder interviews.
Mannion R, Blenkinsopp J, Powell M, et al. Health Services and Delivery Research. Southampton, UK: NIHR Journals Library; 2018.
Staff willingness to speak up about safety and process concerns enables organization and practice improvements that prevent patient harm. This review explores challenges to raising concerns in the National Health Service and discusses policies that support whistleblowers. Further research is needed to examine organizational failures when concerns are reported.
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.
Kelsey R. CRC Press: Boca Raton, FL; 2017. ISBN: 9781498781169.
Characterising the nature of primary care patient safety incident reports in the England and Wales National Reporting and Learning System: a mixed-methods agenda-setting study for general practice.
Carson-Stevens A, Hibbert P, Williams H, et al. Health Services and Delivery Research. Southampton, UK: NIHR Journals Library; 2016.
Management and analysis of incident reporting data must be enhanced in order to realize the potential for learning and improvement from reporting activities. This publication explored primary care incidents reported in England and Wales over an 8-year period. Investigators found inconsistencies and gaps in information collected, including a lack of defined reasons explaining why incidents occurred. Despite weaknesses in the data, they were able to categorize the types of incidents and prioritize system improvements needed to optimize incident reporting as a patient safety improvement strategy.
First Report of Session 2016–17 Report. House of Commons Public Administration and Constitutional Affairs Committee. London, England: The Stationery Office; May 24, 2016. Publication HC 94.
Complaint investigations must be conducted in a consistent manner with a goal of learning from each incident to prevent similar occurrences. This government report summarizes an inquiry into the United Kingdom National Health Service complaint reporting system and suggests that support and training for staff must improve in order to address complaints effectively.
National Health Policy Forum. Washington, DC: George Washington University. March 11, 2016.
This report provides the insights from a panel exploring the need for transparency after a medical mistake occurs. The session discussed the history and evolution of new approaches to achieve transparency, such as communication-and-resolution programs. Experts participating in the session included Dr. David Mayer, Richard Boothman, and Helen Haskell.
McNamara P, Shaller D, De La Mare J, Ivers N. Rockville, MD: Agency for Healthcare Research and Quality; March 2016. AHRQ Publication No. 16-0017-EF.
Sixth Report of Session 2014–15. House of Commons Public Administration Select Committee. London, England: The Stationery Office; March 27, 2015. Publication HC 886.
Applying evidence generated from complaints submitted to health care services has been promoted as a way to inform improvement. As a follow up to a previous inquiry, this report explores the process of clinical incident investigations at the National Health Service. The authors draw from accident analysis practices in the aviation industry to provide guidance on developing an independent program to investigate health care incidents in the United Kingdom.
Hanlon C, Sheedy K, Kniffin T, Rosenthal J. Portland, ME: National Academy for State Health Policy; 2015.
State reporting systems were advocated early in the patient safety movement as a way to enable learning from errors. This analysis of 27 state-level reporting programs highlights that while adverse event reporting has become more sophisticated since the previous survey, only one new program has launched since then. The authors emphasize the value of partnership, collaboration, and transparency in the work of the participating states. An AHRQ WebM&M perspective spotlights state reporting programs as mechanisms to augment patient safety.
Lorincz CY, Drazen E, Sokol PE, et al. Chicago, IL: American Medical Association; 2011.
Although traditionally the majority of patient safety efforts have focused on inpatient care, the overwhelming bulk of health care actually takes place in the ambulatory setting. Accordingly, the scope of widespread documented adverse events among outpatients is vast. Updating a previous report, this publication analyzes efforts to improve patient safety in ambulatory care over the past decade and identifies gaps that future research should address. Dr. Richard Baron discusses patient safety in the office setting in an AHRQ WebM&M perspective.
Washington, DC: National Quality Forum; 2011. ISBN: 9780982842188.
The National Quality Forum originally defined 27 health care "never events"—patient safety events that pose serious harm to patients, but should be considered preventable—in 2002. The 2011 update now consists of 29 events, organized into surgical events (e.g., wrong-site surgery), device events (e.g., air embolism), care management events (e.g., death or disability due to medication errors), patient protection events (e.g., patient suicide), environmental events (e.g., fires), radiologic events, and criminal events. One notable addition to the original list is that serious harm associated with failure to properly follow up on test results is now considered a never event. Since the development and dissemination of this list, many states have mandated that health care facilities report all instances of these events. When such an event occurs, many institutions mandate performance of a root cause analysis.
Harrisburg, PA: Patient Safety Authority; May 2019.
This report summarizes patient safety improvement work in the state of Pennsylvania and reviews the 2018 activities of the Patient Safety Authority, including the launch of the Center of Excellence for Improving Diagnosis, outreach programs, liaison efforts, and the convening of the first patient safety conference for the state.
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.
Portland, OR: Oregon Patient Safety Commission.
This annual publication provides data and analysis of adverse events voluntarily reported to the Oregon Patient Safety Commission. The review of 2015 data discussed the 704 events submitted from the 4 types health care settings involved and found that medication errors, invasive procedure incidents, care delays, and falls were the most frequent problems.
Fillo KT. Bureau of Health Care Safety and Quality, Department of Public Health. Boston, MA: Commonwealth of Massachusetts; July 2018.
This report compiles patient safety data documented by Massachusetts hospitals. The latest numbers represent a modest decrease in serious reportable events recorded in acute care hospitals, from 1012 the previous year to 922. This presentation also includes events from ambulatory surgery centers. Previous years reports are also available.
Omaha, NE: Jones K, Skinner A, Cochran G, Knudson A, Beattie S, Mueller K; for University of Nebraska Medical Center and Nebraska Center for Rural Research; 2007.
Fifty-first Report of Session 2005-06. House of Commons Committee on Public Accounts. London, England: The Stationary Office; July 6, 2006. Publication HC 831.
Inspiring Ideas and Celebrating Successes: A Guidebook to Leading Patient Safety Practices in Ontario Hospitals.
OHA Patient Safety Support Service. Toronto, Ontario, Canada: Ontario Hospital Association; 2006.
This report shares successful patient safety strategies employed in Ontario hospitals to address medication safety, patient incident management, infection issues, and administrative process improvements.
Scobie S, Thomson R. London, England: National Patient Safety Agency; 2005.
Created in 2001 to institute changes in health care across the United Kingdom, the National Patient Safety Agency (NPSA) presents their first report of patient safety incidents. The two-part report begins with a general discussion of incident reporting, the basis for a national reporting system, and the development of the Patient Safety Observatory. The second part builds on this framework by discussing how the acquired data can be used and translated into safer health care strategies. The report itself encompasses more than 85,000 collected incident reports with analysis, comparisons, and case studies to illustrate important safety issues for future efforts. This represents the first of a series of expected reports from NPSA on patient safety data to be published.
McKee J, ed. Oakbrook Terrace, IL: Joint Commission Resources; 2005. ISBN: 0866889116.
This book provides information on implementing the Joint Commission on Accreditation of Healthcare Organization's (JCAHO) Sentinel Event Policy in all health care settings. The text includes a sample sentinel event root cause analysis form and a glossary.