Narrow Results Clear All
- Communication Improvement 14
- Culture of Safety 4
- Education and Training 3
- Error Reporting and Analysis 11
- Human Factors Engineering 3
- Legal and Policy Approaches 8
- Logistical Approaches 1
- Quality Improvement Strategies 7
- Teamwork 1
- Technologic Approaches 1
- Transparency and Accountability 1
- Device-related Complications 2
- Identification Errors 22
- Medical Complications 4
- Medication Safety 3
- Psychological and Social Complications 2
- Surgical Complications
Search results for "Patients"
- Wrong-Site Surgery
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.
Grant T. Washington Post. July 22, 2008:HE01
This article reports on a wrong-sided surgery near miss from the perspective of a parent, and discusses the role of family members in preventing medical errors.
Gulliver D. Herald Tribune. September 3, 2007.
This article describes how the culture around medical errors is evolving to include disclosure and transparency, illustrated by a physician's willingness to discuss a wrong-site surgery.
Cohen E. CNN. March 24, 2016.
Poor communication regarding medical errors can contribute to patient and family frustration and fear. Reporting on a case involving disclosure of a wrong-site surgery, this news article describes a resolution program to help patients cope after a preventable error. The program includes apology, disclosure, and explanation of what occurred as well as financial compensation.
Boodman SG. Washington Post. June 21, 2011:E1.
Rojas-Burke J. The Oregonian. May 25, 2011.
Bernhard B, Kohler J. St. Louis Post-Dispatch. August 1, 2010:A1
In the context of system failures that contributed to the death of a patient, this newspaper article describes how never events are rarely publicized, even though hospital inspection reports are public records.
Stein L. St. Petersburg Times. June 21, 2010.
Reporting on wrong-site surgeries in Florida hospitals, this newspaper article describes how timeouts have changed the nature and frequency of surgical errors.
Cohen E. Empowered Patient. CNN.com. November 13, 2009.
This news story describes an incident of patient misidentification and offers tips to help patients confirm their care during a hospitalization.
National Priorities Partnership. Washington, DC: National Quality Forum; 2008. ISBN: 1933875194.
This report resulted from a consensus program involving 28 national organizations that sought to outline goals for improving the US health care system and share examples of such efforts in patient safety and other identified areas.
Freyer FJ. Providence Journal. September 20, 2008.
This story reports on an incident involving wrong-side surgery and describes how the hospital responded to the event.
Herper M, Lindner M. Forbes. August 25, 2008.
This article discusses common medical complications and care failures, and provides an annotated picture gallery of several hospital complications and how they can be prevented.
Smith S. Boston Globe. July 30, 2008;Metro section:1A.
This article reports on the incidence of wrong site surgeries in Massachusetts and describes complex factors that may contribute to such errors occurring in spinal surgery.
Smith S. Boston Globe. July 4, 2008;Metro section:1A.
This article reports on a wrong-side surgery that was immediately disclosed to the patient along with an apology. Hospital administrators also disclosed the error to staff.
Associated Press. MSNBC. November 27, 2007.
This news article reports repeated incidents of wrong-side surgery at the same facility, and state and hospital reactions to the errors.
Kowalczyk L. Boston Globe. October 26, 2007;Metro section:1A.
This article investigates the causes of surgical errors reported in recent years by Massachusetts hospitals, and identifies team training and instrument bar-coding as solutions for improvement.
East Perth, WA, Australia: Department of Health of Western Australia; 2006.
This report shares the 2005-2006 results of Western Australia's sentinel event reporting program and documents a reduction in two types of events: wrong site/wrong part surgeries and retained foreign objects.
Journal Article > Commentary
The author explains the Joint Commission on Accreditation of Healthcare Organizations' Universal Protocol on surgical site verification in the context of its implementation in a New Jersey hospital.
Davis R. USA Today. April 17, 2006.
This article reports on a recent AHRQ-funded study on the incidence of wrong-site surgery and shares various perspectives on the issue.
Journal Article > Study
Waterman AD, Gallagher TH, Garbutt J, Waterman BM, Fraser V, Burroughs TE. J Gen Intern Med. 2006;21:367-370.
This AHRQ–funded study used more than 2000 telephone interviews with recently discharged patients to demonstrate that patients who are most comfortable with error prevention were more likely to take specific action compared to those who are less comfortable. The authors report that although the majority of patients expressed comfort in asking questions about medications and general medical questions, far fewer actively engaged in marking their incision site or asking about handwashing. A past study discussed how to improve patients' perceptions of safety in hospitals, including educational interventions that might empower patients to take greater preventive action, as outlined in this study.