Narrow Results Clear All
- Review 1
- Study 1
- Slideset 1
- Legislation/Regulation 4
- Special or Theme Issue 1
- Toolkit 4
- Web Resource 125
- Award 2
- Meeting/Conference 3
- Communication Improvement 51
- Culture of Safety 54
- Education and Training 35
Error Reporting and Analysis
- Never Events 21
- Error Reporting 143
- Human Factors Engineering 14
Legal and Policy Approaches
- Regulation 14
- Logistical Approaches 6
- Policies and Operations 3
Quality Improvement Strategies
- Benchmarking 17
- Research Directions 3
- Specialization of Care 5
- Teamwork 12
- Clinical Information Systems 8
- Transparency and Accountability 12
- Device-related Complications 9
- Diagnostic Errors 12
- Discontinuities, Gaps, and Hand-Off Problems 19
- Drug shortages 2
- Failure to rescue 1
- Fatigue and Sleep Deprivation 2
- Identification Errors 9
- Inpatient suicide 1
- Medical Complications 48
- Medication Errors/Preventable Adverse Drug Events 26
- Nonsurgical Procedural Complications 7
- Overtreatment 1
- Psychological and Social Complications 24
- Second victims 1
- Surgical Complications 34
- Transfusion Complications 1
- Allied Health Services 1
- Internal Medicine 77
- Nursing 4
- Pharmacy 10
- Family Members and Caregivers 7
- Health Care Executives and Administrators 285
Health Care Providers
- Nurses 2
- Physicians 19
Non-Health Care Professionals
- Media 6
- Patients 51
- Australia and New Zealand 6
- Europe 89
- Canada 13
United States of America
United States Federal Government
- Department of Health and Human Services (HHS) 54
- United States Federal Government 78
Search results for "Error Reporting and Analysis"
- Error Reporting and Analysis
The Financial and Human Cost of Medical Error... and How Massachusetts Can Lead the Way on Patient Safety.
Boston, MA: Betsy Lehman Center for Patient Safety; June 2019.
The Betsy Lehman Center is a nonregulatory Massachusetts state agency that works to coordinate provider, patient, and policy maker efforts to reduce medical errors. This report describes the results of two studies conducted by the Center and includes a retrospective analysis of insurance claims associated with preventable medical errors. Investigators identified nearly 62,000 errors and calculated excess claim costs due to medical errors of more than $617 million over a 12-month period. The Center also conducted a patient survey exploring harms from medical errors. Respondents reported loss of trust and suboptimal disclosure practices around medical errors. These results collectively convey ongoing, large-scale safety gaps in health care delivery. A past PSNet perspective discussed the tragic error involving Betsy Lehman, who died due to an inadvertent overdose of chemotherapy while receiving treatment for breast cancer at the Dana-Farber Cancer Institute.
Lives Lost, Lives Saved: An Updated Comparative Analysis of Avoidable Deaths at Hospitals Graded by The Leapfrog Group.
Austin M, Derk J. Baltimore, MD: Armstrong Institute for Patient Safety and Quality, and Johns Hopkins Medicine; May 2019.
Measures help track gaps in process and evidence of safety improvements. This white paper examines the performance of hospitals receiving Hospital Safety Grades and the relationship between high-level recognition and preventable harm. The report estimates that a substantial number of lives could have been saved if performance metrics had been met, but concludes that even high-performing hospitals exhibit areas in need of improvement.
Omaha, NE: Nebraska Coalition for Patient Safety; 2019.
Patient Safety Organizations (PSOs) provide local evidence to inform learning among their members. This annual report describes a state-wide PSO's activities, summarizes breakdowns of data collected between 2008 and 2018, offers insights drawn from an analysis of nearly 1000 incident reports, and reviews root causes analyses on incidents such as patient suicide.
CHPSO: Sacramento, CA; 2019.
Patient Safety Organizations (PSOs) capture and analyze local data to inform learning among their members. This report highlights 2018 trends, activities, and outcomes of initiatives at a 10-state PSO. Sections of the report include high-level review of reported medication and perinatal events, safe table data analysis, and strategies to improve incident reporting.
Newcastle Upon Tyne, UK: Care Quality Commission; October 2018.
This website provides access to an annual report that summarizes National Health Service hospital and social care performance across a range of care quality metrics at both the trust and service level. Most facilities were found to be improving their care quality and basic performance was found to be high. However the latest report found substantial gaps in mental health care delivery that affect the safety of patients.
Washington, DC: Commission on Care; June 2016.
The Veterans Affairs health system has recently faced challenges associated with access and quality. Providing an assessment of the current and future state of the Veterans Health Administration, this report determined that care quality often meets or exceeds expectations but that quality varies from location to location. The authors outline recommendations for system improvements to ensure the safety of care delivery.
Mayer E, Flott K, Callahan R, Darzi A. London, UK: NIHR Imperial Patient Safety Translational Research Centre; 2016.
Incident reporting has achieved varying levels of success in encouraging transparency and facilitating system learning. This publication discusses reporting initiatives in the National Health Service and focuses on the importance of considering system purpose, user experience, data integrity, and feedback process to enhance reporting systems.
Washington, DC: United States Government Accountability Office; February 2016. Publication GAO-16-308.
Despite support for evidence-based medicine as a strategy to improve safety and quality, reliable use of best practices is lacking. Analyzing how six hospitals tried to implement evidence-based safety practices, this report identified in-house incident data use, practice selection, and implementation consistency as challenges to sustainable use of best practices.
Effective board governance of safe care: a (theoretically underpinned) cross-sectioned examination of the breadth and depth of relationships through national quantitative surveys and in-depth qualitative case studies.
Mannion R, Freeman T, Millar R, Davies H. Health Serv Deliv Res. 2016;4:1-165.
This mixed-methods analysis of four trusts in the National Health Service (NHS) found that evident board commitment and behavior supporting safety encourages staff to raise concerns that can lead to improvements. The authors suggest their results should help to inform hospital board training and recruitment efforts across the NHS.
Computerized Prescriber Order Entry Medication Safety (CPOEMS): Uncovering and Learning From Issues and Errors.
Brigham and Women's Hospital, Harvard Medical School, Partners HealthCare. Silver Spring, MD: US Food and Drug Administration; December 15, 2015.
Electronic prescribing, considered an opportunity to reduce medication errors, has been linked to problems unique to technology use. This white paper discusses the results of a multi-hospital effort to develop a process and tools to collect and analyze data related to search, display, and workflow issues associated with computerized provider order entry. The authors offer recommendations to enhance the safety of electronic prescribing, including standardizing drug names, minimizing the number of alerts, and designing better search functions.
Boston, MA: National Patient Safety Foundation; 2015.
This report provides an objective assessment of the state of the safety field 15 years after the release of the Institute of Medicine's To Err Is Human. Acknowledging that progress has been slower than anticipated, the report makes eight recommendations for achieving total system safety, including creating a common set of safety metrics that reflect meaningful outcomes, establishing and sustaining a culture of safety, centralizing oversight of patient safety at the national level, improving the safety of information technology, and supporting patients, families, and the health care workforce. The report also highlights the need for greater investment in patient safety, particularly in the outpatient and long-term care areas. Dr. Tejal Gandhi, President and CEO of the National Patient Safety Foundation (NPSF), discussed the evolving responsibilities of NPSF in a 2014 PSNet interview.
Syed M. New York, NY: Portfolio; 2015. ISBN: 9781591848226.
Short-Life Working Group on Hospital Reports. Edinburgh, Scotland: Academy of Medical Royal Colleges and Faculties in Scotland; May 2015.
Substantive reports of failures have transparently discussed problems in the National Health Services (NHS) and proposed solutions. Exploring NHS care in Scotland, this publication reviews weaknesses that affect health service delivery and makes recommendations to improve leadership, staffing, and external assessment of processes to ensure safe high quality care.
Department of Health. London, England: Crown Publishing; July 2015. ISBN: 9781474123716.
The National Health Service (NHS) has a history of sharing analyses of problems in its system. This publication contains the government response to three reports on system failures at the NHS: the Freedom to Speak Up review, the Investigating Clinical Incidents in the NHS report, and the Morecambe Bay Investigation. Common recommendations in the three reports included the need to support open discussions about what went wrong, learning from error, and a culture of safety.
Blumenthal D, Malphrus E, McGinnis JM, eds. Committee on Core Metrics for Better Health at Lower Cost, Institute of Medicine. Washington, DC: National Academies Press; 2015. ISBN: 9780309324939.
Measures to assess health care often add burden for overwhelmed hospital workers, and lack of consistency limits the usability of data to inform improvement. This publication reviews findings of a committee convened to discuss core measures for health care and outlines a set of 15 standardized measures to optimize performance assessment and develop data that drives progress.
Dekker S. Aldershot, UK: Ashgate Publishing; 2014. ISBN: 9781472439048.
This revised and reorganized book provides a primer on how human error causes mishaps and often illustrates deeper troubles within a system. Both the old view of human error that places blame on the individual and the new view that identifies most human failures as merely a symptom of systems-level problems are presented. This view of human error has led to the application of root cause analyses and human factors engineering in health care. New chapters discuss the importance of safety culture and provide recommendations on improving the failure investigation process.
Oakbrook Terrace, IL: The Joint Commission; November 2014.
This Joint Commission annual report shows continued improvements in quality of care in hospitals across the United States. This year's list of Top Performers included a record 1224 hospitals, representing nearly 37% of all reporting Joint Commission-accredited hospitals. Even as The Joint Commission has added new accountability measures over the past few years for stroke care, venous thromboembolism, perinatal care, and immunizations, the number of hospitals reaching at least a 95% composite accountability score has more than tripled in the past 4 years. Major gains were found this year in the quality of perinatal care, children's asthma, venous thromboembolism, and inpatient psychiatric services. Heart attack care now has a composite score of 99%.
Washington, DC: National Quality Forum; 2016.
The value of current measures to track patient safety has been called into question. This technical report provides information about a consensus-driven initiative to evaluate the reliability of existing patient safety measures in tracking and assessing safety in hospitals, across various populations and settings. The related website offers resources related to the project history.
Manchester, UK: General Medical Council; November 2014.
Battles JB, Cleeman JI, Kahn KL, Weinberg DA, eds. Rockville, MD: Agency for Healthcare Research and Quality; June 2014. AHRQ Publication No. 14-0003.
Health care–associated infections (HAIs) are a known contributor to preventable patient harm. This AHRQ publication offers 19 papers that explore government-funded research into HAIs, including lessons learned from the design and implementation of prevention efforts along with projects that sought to detect and measure HAI incidents to determine risks. The report discusses specific infections, including clostridium difficile and methicillin-resistant staphylococcus aureus, as well as common conditions, such as central line-associated blood stream infections and catheter-associated urinary tract infections. A recent AHRQ WebM&M perspective reviews how infection prevention fits into a safety program.