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- Communication Improvement 4
- Culture of Safety 1
- Error Reporting and Analysis 14
- Legal and Policy Approaches 6
- Quality Improvement Strategies
- Specialization of Care 1
- Teamwork 1
- Technologic Approaches 1
- Medical Complications 8
- Medication Safety 3
- Psychological and Social Complications 2
- Surgical Complications 4
- Transfusion Complications 1
- Family Members and Caregivers 1
- Health Care Executives and Administrators 16
- Health Care Providers 15
Non-Health Care Professionals
- Media 1
Search results for "Patients"
Web Resource > Government Resource
National Patient Safety Agency.
This Web site provides data on safety incidents from the United Kingdom in the form of workbooks sorted by either organization or region.
Web Resource > Government Resource
Centers for Medicare & Medicaid Services.
The Centers for Medicare and Medicaid Services (CMS) provides consumers with publicly available information on the quality of Medicare-certified hospital care through this Web site. The site includes specific information for both patients and hospitals on how to use the data to guide decision-making and improvement initiatives. Most recently, listings from the Hospital-Acquired Condition Reduction Program (HACRP) and data on Department of Veterans Affairs hospitals were added to the reports available.
Balik B, Conway J, Zipperer L, Watson J. Cambridge, MA: Institute for Healthcare Improvement; 2011.
This white paper identifies drivers of patient-centered care, and provides tools to help organizations improve the patient and family experience.
Rau J. Kaiser Health News. October 17, 2011.
The Centers for Medicare & Medicaid Services (CMS) published data on hospital-acquired conditions in a 2011 report. This news article discusses new data available on the Hospital Compare Web site, including preventable complications and certain types of medical errors.
Graham J. Los Angeles Times. May 11, 2011.
This newspaper article reports on common errors that may occur during hospitalization and offers tips for patients to participate in their safety.
Golden, CO: HealthGrades, Inc.; March 2010.
This report, the latest in an annual series, uses the Agency for Healthcare Research and Quality's Patient Safety Indicators (PSIs) to estimate the incidence of preventable patient safety events, estimate the attributable morbidity and mortality from such events, and identify hospitals with lower rates of PSIs. It is important to note that prior research has questioned the validity of using PSIs for hospital comparison purposes.
Golden, CO: HealthGrades, Inc.; April 2009.
This analysis of patient safety in Medicare patients from 2005–2007 concludes that while modest improvements have been made, patient safety incidents still account for nearly 100,000 preventable deaths and nearly $7 billion in excess costs yearly. The report also recognizes the best performing hospitals with a "Patient Safety Excellence Award"—hospitals scoring in the top 15% according to a ranking methodology developed by the authors. As with prior HealthGrades reports, the study uses the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSIs) to measure the incidence of patient safety problems and compare hospitals. The limitations of using PSIs as a performance measure have been discussed in a prior study and AHRQ WebM&M commentary, and it is important to note that this report did not undergo external peer review.
Esmail N, Hazel M. Studies in Health Care Policy. Fraser Institute. Calgary, Alberta, Canada; March 2009. ISSN: 1918-2082.
Designed to help patients choose hospitals, this report utilized AHRQ quality indicators to analyze the performance of acute-care hospitals in Ontario. Using an interactive online tool, consumers can look up a particular condition or procedure and compare rates of procedure volume, adverse events, deaths, and utilization.
Web Resource > Multi-use Website
Dallas, TX: American College of Emergency Physicians.
This Web site provides access to emergency medical services evaluations in four categories: access, quality and patient safety, public health and prevention, and medical liability environment. The site also offers an interactive map of the nation, with detailed information and a "grade" for each state.
Kershaw S. New York Times. Sepember 7, 2007;Metro Desk section:B1.
This article reports on an initiative to publish data on mortality and hospital-acquired infections in New York City public hospitals.
Ottawa, ON, Canada: Canadian Institute for Health Information; August 14, 2007.
Using survey data as well as information on patient safety indicators, this report provides an update on the frequency of certain types of errors and incidents in Canada.
Golden, CO: HealthGrades, Inc.; April 2007.
This fourth annual report on the safety of hospitalized Medicare patients builds on past efforts to evaluate hospital performance. The report uses the Agency for Healthcare Research and Quality's Patient Safety Indicators to provide benchmarks for such performance, identify current trends in safety issues, and estimate preventable events nationally. The report suggests that the patient safety incidents captured account for nearly $9 billion in excess cost during 2003-2005, and nearly 250,000 potentially preventable deaths occurred during the same time period. Grading for all states and a selected group of highly rated hospitals is included with the implication that, if all hospitals performed at a level comparable to the ones acknowledged, more than 34,000 Medicare deaths could be avoided with a cost savings of $1.74 million. As with the second and third annual reports, several methodological limitations exist, and the reports themselves did not receive external peer review.
Journal Article > Commentary
Health information technology is a vehicle, not a destination: a conversation with David J. Brailer.
Milstein A. Health Aff (Millwood). 2007;26:w236-w241.
Brailer, the National Coordinator for Health Information Technology ("the IT Czar") from 2004-2006, discusses the fundamental changes needed for the United States to optimize the use of health information technology, including patient ownership of their health care information, universal access to provider performance data, and changes in health care policy.
Wisc Med J. 2006:105;1-86.
This special issue includes articles on programs and initiatives to improve the safety of health care. It also includes proceedings from a 2006 Wisconsin conference on patient safety.
Berwick DM, Leape LL. Newsweek. October 16, 2006:70-71.
As part of the "Health for Life" series, Drs. Berwick and Leape discuss the notion of completely eliminating medical errors and share stories about several hospitals' efforts to raise safety standards.
Kaiser Family Foundation, Agency for Healthcare Research and Quality; September 2006.
This survey follows up on a prior study from 2004, asking patients about their perceptions of health care quality and medical errors. The study found minimal change since 2004 in overall impression of US health care quality, with approximately half of respondents stating they are "dissatisfied" with quality, particularly with coordination of care. More patients are aware of information comparing the quality of hospitals, health care plans, or providers, but only a small minority report using this information to make health care decisions. A large proportion of patients reported taking recommended actions to improve safety, such as bringing a list of their medications to appointments or following up on test or procedure results. As found in other studies, survey respondents overwhelmingly expressed support for full, mandatory disclosure of all preventable errors, and two-thirds felt errors should be publicly reported.
Mirror, Mirror on the Wall: An Update on the Quality of American Health Care Through the Patient's Lens.
Davis K, Schoen S, Schoenbaum SC, et al. New York, NY: The Commonwealth Fund; April 2006.
This report presents findings from a cross-national survey of consumer views of health care. Findings are presented based on the aims for quality care outlined in Crossing the Quality Chasm and reveal that the United States has low rankings from the patient perspective when compared with the other five countries profiled.
Golden, CO: Health Grades, Inc.; April 2006.
This third annual report on the safety of hospitalized Medicare patients builds on past efforts to evaluate hospital performance. The report uses the Agency for Healthcare Research and Quality's Patient Safety Indicators to provide benchmarks for such performance, identify current trends in safety issues, and estimate preventable events nationally. The report suggests that the patient safety incidents captured account for more than $9 billion in excess cost during 2002-2004, and more than 250,000 potentially preventable deaths occurred during the same time period. Grading for all states and a selected group of highly rated hospitals is included with the implication that, if all hospitals performed at a level comparable to the ones acknowledged, more than 44,000 Medicare deaths could be avoided with a costs savings of $2.45 million. As with the second annual report, several methodological limitations exist, and the reports themselves did not receive external peer review.
Journal Article > Study
Patient assessments of a hypothetical medical error: effects of health outcome, disclosure, and staff responsiveness.
Cleopas A, Villaveces A, Charvet A, Bovier PA, Kolly V, Perneger TV. Qual Saf Health Care. 2006;15:136-141.
This study presented a medication error scenario to a group of recently discharged patients and discovered that patients viewed the error less favorably in association with a slow hospital response, a lack of disclosure, and the presence of serious health effects. Using a mailed questionnaire, investigators achieved a 70% response rate from eligible patients, providing more than 1200 evaluations of the scenario. The three primary findings noted above appeared additive and, in particular, the finding that slow and ineffective handling of the error by health care staff produced a more negative response independent of disclosure. A past study similarly discussed patient and physician attitudes regarding the disclosure of medical errors.
Journal Article > Study
Agoritsas T, Bovier PA, Perneger TV. J Gen Intern Med. 2005;20:922-928.
The authors surveyed adults recently discharged from a Swiss hospital and found that patients can effectively pinpoint in-hospital adverse events.