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- WebM&M Cases 14
- Perspectives on Safety 2
- Commentary 29
- Review 15
- Study 77
- Audiovisual 14
- Book/Report 27
- Legislation/Regulation 10
- Newspaper/Magazine Article 87
- Newsletter/Journal 1
- Special or Theme Issue 4
- Tools/Toolkit 1
- Web Resource 25
- Award 6
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Education and Training
- Students 1
Error Reporting and Analysis
- Never Events 12
- Error Reporting 51
- Human Factors Engineering 19
Legal and Policy Approaches
- Regulation 51
- Logistical Approaches 21
- Policies and Operations 3
Quality Improvement Strategies
- Benchmarking 14
- Research Directions 1
- Specialization of Care 2
- Teamwork 9
- Clinical Information Systems 15
- Transparency and Accountability 4
- Device-related Complications 18
- Diagnostic Errors 33
- Discontinuities, Gaps, and Hand-Off Problems 27
- Drug shortages 6
- Failure to rescue 1
- Fatigue and Sleep Deprivation 8
- Identification Errors 2
- Inpatient suicide 1
- Interruptions and distractions 3
- Medical Complications 84
- Medication Errors/Preventable Adverse Drug Events 30
- Nonsurgical Procedural Complications 3
- Overtreatment 1
- Psychological and Social Complications 13
- Surgical Complications 21
- Transfusion Complications 2
- Ambulatory Care 28
- General Hospitals 35
- Long-Term Care 20
- Outpatient Surgery 3
- Patient Transport 2
- Allied Health Services 1
- Geriatrics 28
- Pediatrics 9
- Primary Care 21
- Internal Medicine
- Nursing 16
- Pharmacy 14
- Family Members and Caregivers 6
- Health Care Executives and Administrators 180
Health Care Providers
- Nurses 6
- Physicians 21
Non-Health Care Professionals
- Educators 13
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- Africa 1
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- Australia and New Zealand 6
- Central and South America 1
- Europe 19
- Canada 7
United States of America
United States Federal Government
- Department of Health and Human Services (HHS) 18
- United States Federal Government 26
Search results for "Legal and Policy Approaches"
- Internal Medicine
- Legal and Policy Approaches
Simmons-Ritchie D. Penn Live. November 15, 2018.
Nursing home patients are vulnerable to preventable harm due to poor safety culture, insufficient staffing levels, lack of regulation enforcement, and misaligned financial incentives. This news investigation reports on how poor practices resulted in resident harm in Pennsylvania nursing homes and discusses strategies for improvement, such as enhancing investigation processes.
Journal Article > Study
Centers for Medicare and Medicaid Services hospital-acquired conditions policy for central line–associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI) shows minimal impact on hospital reimbursement.
Calderwood MS, Kawai AT, Jin R, Lee GM. Infect Control Hosp Epidemiol. 2018;39:897-901.
The Centers for Medicare and Medicaid Services (CMS) nonpayment policy for health care–associated infections is widely viewed as a catalyst for infection prevention initiatives. This analysis of Medicare fee-for-service claims data shows that following nonpayment policy implementation, there was a substantial increase in claims in which central line–associated bloodstream infections and catheter-associated urinary tract infections were reported to be present on arrival to the hospital. According to this analysis, because CMS continued to reimburse hospitals for conditions present on arrival, the nonpayment policy did not have significant financial impact. The authors conclude that the nonpayment policy for health care–associated infections did not have its intended effect. A past PSNet interview discussed the potential benefits and limitations of insurers not paying for preventable complications.
Journal Article > Review
Hospital board oversight of quality and patient safety: a narrative review and synthesis of recent empirical research.
Millar R, Mannion R, Freeman T, Davies HTO. Milbank Q. 2013;91:738-770.
Hospital leadership oversight is thought to be critical for advancing patient safety initiatives. This narrative review synthesized 122 studies examining the role of hospital board oversight in fostering safety practices. Investigators found that high-performing hospitals are more likely to have skilled board members and standardized board processes compared with low-performing hospitals, highlighting the value of effective and committed leadership that prioritizes quality and safety improvement. However, more research is needed to determine optimal hospital governance. A past AHRQ WebM&M interview discussed the role of leadership and medical administration in patient safety.
ISMP Medication Safety Alert! Acute Care Edition. March 8, 2012;17:1-3.
This newsletter piece discusses the pros and cons of physicians dispensing medications and its impact on patient safety.
Terry K. Hosp Health Netw. July 2011;85:38-40, 42.
This article discusses strategies that health care leaders use to drive hospital-based patient safety efforts.
Journal Article > Study
Van Den Bos J, Rustagi K, Gray T, Halford M, Ziemkiewicz E, Shreve J. Health Aff (Millwood). 2011;30:596-603.
The Centers for Medicare and Medicaid Services stopped reimbursing hospitals for additional costs associated with certain preventable adverse events in 2008. Despite the widespread controversy engendered by this policy, the actual financial effect has been small, leading to calls for expansion of the policy. This actuarial study used a case-control approach to estimate the annual marginal cost of preventable adverse events in hospitalized patients at $17.1 billion, largely attributable to post-surgical complications, health care–associated infections, and pressure ulcers. Never events accounted for approximately $3.7 billion in excess costs. The results of this study provide targets for policy efforts to control health care costs and improve patient safety.
Journal Article > Study
Increases in mortality, length of stay, and cost associated with hospital-acquired infections in trauma patients.
Glance LG, Stone PW, Mukamel DB, Dick AW. Arch Surg. 2011;146:794-801.
This study found that health care–associated infections were linked to significant increases in mortality, length of stay, and costs in a large population of trauma patients.
Carrier E, Yee T, Holtzwart RA. Washington, DC: National Institute for Health Care Reform; 2011. NIHCR Research Brief No. 3.
This report analyzes communication practices between emergency and primary care physicians and provides suggestions to improve and encourage meaningful communication.
Wetzel TG. Hosp Health Netw. 2010 Oct;84:41-2, 44, 2.
This article describes how hospital responses to adverse events have affected disclosure process strategies.
Austin, TX: Texas Medical Institute for Technology and the Quaid Foundation; 2010.
This documentary reports on families affected by medical errors; it includes the story of a high-profile heparin overdose and how it transformed the family of actor Dennis Quaid into advocates for patient safety.
Journal Article > Study
McCullough JS, Casey M, Moscovice I, Prasad S. Health Aff (Millwood). 2010;29:647-654.
This study found that adoption of CPOE and electronic health records, which are utilized more in academic settings, can result in improved care for targeted quality measures. The authors discuss their findings in the context of suggested policy changes that call for wider adoption of health information technology nationally.
Larkin H. Hosp Health Netw. October 21, 2009.
In this piece, five health care leaders briefly assess the impact of To Err Is Human and describe future directions for the patient safety community.
Peters PG Jr. Regulation. Summer 2009;32:30-36.
The author explains how shifting liability from individual physicians to hospitals could deter systems-based failures and improve working conditions for clinicians.
Web Resource > Multi-use Website
1215 K Street, Suite 800, Sacramento, CA 95814.
This Website offers tools, a newsletter focusing on lessons learned from error reports, a set of specialized checklists, and a detailed resource collection to support patient safety organization (PSO) efforts in California. In addition, the group--formerly known as the California Hospital Patient Safety Organization--coordinates the Nationwide Alliance of Patient Safety Organizations (NAPSO) to enable learning across the sector.
Failed check system for chemotherapy leads to pharmacist's "no contest" plea for involuntary manslaughter.
ISMP Medication Safety Alert! Acute Care Edition. April 23, 2009;14:1-2.
This article examines a case in which a health care professional faces criminal charges for a medication error. The piece discusses how criminalization of errors in health care could thwart broader efforts to learn from mistakes.
Palmer J. Patient Saf Qual Healthc. May/June 2019.
Organizations must learn from adverse events to prevent similar incidents. Reporting on lessons to be learned from the cascade of failures connected with the preventable death of a patient during an acute asthma attack at the door of a hospital emergency department, this magazine article outlines the importance of effective signage, appropriate security staff placement, and acceptance of the responsibility for failure.
Journal Article > Commentary
Stonington S, Coffa D. N Engl J Med. 2019;380:701-704.
The authors describe how increasing complexity and bureaucracy associated with opioid prescribing led a patient with chronic pain that had been previously well controlled on a stable dose of acetaminophen–hydrocodone for many years to experience job insecurity, withdrawal symptoms, and uncontrolled pain, which ultimately prompted him to seek opioids illegally. The authors refer to this type of harm as "structural iatrogenesis."
AHRQ National Scorecard on Hospital-Acquired Conditions Updated Baseline Rates and Preliminary Results 2014–2017.
Rockville, MD: Agency for Healthcare Research and Quality; January 2019.
Hospital-acquired conditions (HACs) represent a significant source of preventable harm to patients. The Centers for Medicare and Medicaid Services financially penalizes hospitals with increased numbers of HACs through the Hospital-Acquired Condition Reduction Program. This policy of nonpayment has prompted hospitals to focus significant resources on preventing HACs. This AHRQ report found a reduction in HACs from 99 per 1000 acute care discharges to 86 per 1000 discharges between 2014 and 2017, representing a decrease in 910,000 HACs and savings of $7.7 billion. Declines in certain HACs such as adverse drug events and Clostridium difficile infections were noted to be more significant as compared to others. A past WebM&M commentary highlighted the clinical significance of HACs and described an incident involving a patient who developed a pressure ulcer while in the hospital.
Rau J. Kaiser Health News. December 3, 2018.
Mohr H, Weiss M. Associated Press. November 27, 2018.