Narrow Results Clear All
- Communication Improvement 19
- Culture of Safety 21
- Education and Training 25
Error Reporting and Analysis
- Error Reporting 25
- Human Factors Engineering 6
- Legal and Policy Approaches 16
- Logistical Approaches 2
- Policies and Operations 2
- Quality Improvement Strategies 41
- Research Directions 2
- Specialization of Care 2
- Teamwork 6
- Technologic Approaches 6
- Transparency and Accountability 2
- Device-related Complications 2
- Diagnostic Errors 6
- Discontinuities, Gaps, and Hand-Off Problems 11
- Drug shortages 1
- Medical Complications 9
- Medication Errors/Preventable Adverse Drug Events 10
- Nonsurgical Procedural Complications 3
- Overtreatment 1
- Psychological and Social Complications 7
- Surgical Complications 12
- Transfusion Complications 1
- Allied Health Services 1
- Internal Medicine 32
- Nursing 2
- Pharmacy 4
- Family Members and Caregivers 2
- Health Care Executives and Administrators 102
Health Care Providers
- Nurses 3
- Physicians 15
Non-Health Care Professionals
- Educators 11
- Media 2
- Patients 14
Search results for "Europe"
Geneva, Switzerland: World Health Organization; 2019.
Reducing adverse medication events is a worldwide challenge. This collection of technical reports explores key areas of concern that require action at a system level to improve: high-alert medications, polypharmacy, and medication use at care transitions. Each monograph provides an overview of the topic as well as practical improvement approaches for patients, clinicians, and organizations.
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.
Cullen A. Uitgeverij van Brug: The Hague, The Netherlands; 2019. ISBN: 9789065232236.
Patient stories offer important insights regarding the impact medical errors have on patients and their families. This book shares the author's experience with medical error and spotlights how lack of transparency in European health care can contribute to avoidable process failures that result in patient harm.
London, UK: Royal College of Surgeons of England; 2019.
Physical demands and technical complexities can affect surgical safety. This resource is designed to capture frontline perceptions of surgeons in the United Kingdom regarding concerning behaviors exhibited by their peers during practice to facilitate awareness of problems, motivate improvement, and enable learning.
Lau F, Bartle-Clar JA, Bliss G, et al, eds. Stud Health Technol Inform. 2019;257:1-539. ISBN: 9781614999508.
Information technology is prevalent in health care and is associated with both optimized processes and unintended consequences. This publication is a compilation of papers from an international conference that explored the potential of health information technology and the research needed to achieve success. Topics covered include usability, implementation, interoperability, and policy.
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.
Newcastle upon Tyne, UK: Care Quality Commission; December 2018.
The term never events was originally coined to describe rare, devastating, and preventable events. This report provides an analysis of National Health Service (NHS) efforts to optimize use of alerts, guidance, and recommendations to prevent never events. The investigation found that NHS staff feel unsupported by training, challenged by complex processes of care to practice safely, and uncertainty regarding improvement roles at the system level.
Executive Board EB144/29 144th session. Geneva, Switzerland: World Health Organization; December 12, 2018.
This guidance summarizes the current status of global patient safety, highlights World Health Organization efforts to address the problem, and provides direction for WHO leadership and policy makers to achieve improvements in safety. Recommendations include universal health coverage, coordination of efforts, and dissemination of effective practices.
Pedersen KZ. London, United Kingdom: Palgrave Macmillan; 2018. ISBN: 9781137537850.
The book suggests that though a systems orientation to safety improvement is the correct approach, it can be complex and difficult to operationalize. The author explores the unintended influences of blame-free methodologies, challenges the belief that fixing the system will prevent all error, and cautions health care to moderate patient engagement efforts.
Watts E, Rayman G. Diabetes UK. London, UK; 2018.
Chronic disease management can add complexity to inpatient care regimens. Researchers worked with patients, system leaders, and clinicians to examine areas of risk for hospitalized patients with diabetes and determine solutions such as specialized teams, clinical leadership, and improved use of technology. A WebM&M commentary illustrated safety challenges associated with providing care for hospitalized patients with diabetes.
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.
London, UK: Royal College of Physicians; 2018. ISBN: 9781860167270.
Lack of appropriate staffing can diminish the safety and effectiveness of medical services. This report explored staffing levels in United Kingdom trusts for three tiers of expertise and found them to be inadequate across the system. The paper provides recommendations for staffing decisions for individual organizations and emphasizes the need for improved focus on care provision during routine working hours to support a healthy work force and safe patient care.
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.
Keen J, Nicklin E, Long A, et al. Health Services and Delivery Research. Southampton, UK: NIHR Journals Library; 2018.
The National Health Service (NHS) is a global leader in patient safety improvement. This report reviews the results of a study that explored whether staff had access to information needed to prevent errors. Clinicians in four acute NHS hospitals were surveyed to assess how information is used by nurses, staff, and senior hospital managers. The report concluded that robust access to patient information improved care and proactive risk management activities.
Slawomirski L, Auraaen A, Klazinga N. Paris, France: Organisation for Economic Co-operation and Development; 2018.
The global economic impact of medical error is substantial. This report expands on a 2017 analysis to address a gap in understanding about the impact of medical mistakes in ambulatory and primary care environments across 29 countries. The authors found iatrogenic harm and associated disease burden in outpatient care to be concerning and suggest the need for policy and leadership to design and implement improvement strategies.
Department of Health and Social Care. London, England: Crown Publishing; February 2018.
Medication errors are a prominent challenge for health care systems worldwide. This report provides recommendations that align with the World Health Organization medication safety improvement effort to address medication failures in the National Health Service. The authors suggest an emphasis on technology, teamwork, and safety culture to enable sustained improvements across the system.
Elliott RA, Camacho E, Campbell F, et al. Policy Research Unit in Economic Evaluation of Health and Care Interventions. Sheffield, United Kingdom: University of Sheffield and University of York; 2018.
Medication errors represent a significant source of preventable patient harm. Prior research has shown that medication errors occur frequently and are associated with a longer hospital stay and increased costs. This report from the Policy Research Unit in Economic Evaluation of Health and Care Interventions synthesizes the evidence regarding the burden of medication errors in the England. The authors estimate that 237 million medication errors occur annually and that 66 million of these errors may be clinically significant. The majority of potentially harmful errors likely occur in the outpatient setting where most medications in the National Health Service are prescribed. Costs associated with errors seem to vary widely. A prior WebM&M commentary described a case in which a medication error led to serious patient harm.
London, UK: Parliamentary and Health Service Ombudsman; 2017. ISBN: 9781528601344.
Patients with mental health conditions face particular safety challenges. This report describes incidents involving patients with eating disorders who experienced harm while receiving care in National Health Service organizations. Factors that contributed to the failures included poor care coordination, premature discharge, and lack of monitoring. The report discusses gaps in the investigations of these patient deaths and outlines areas of improvement.
Comptroller and Auditor General, Department of Health; London, UK: National Audit Office; 2017. ISBN: 9781786041395.
Applying evidence generated from complaints submitted to health care services has been promoted as a way to inform improvement. This report assesses management of claims against National Health Services trusts to determine the costs involved, ensure appropriate patient compensation, and control incidence of future claims through collaborative care improvement efforts.