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- Error Reporting and Analysis 4
- Legal and Policy Approaches 2
- Quality Improvement Strategies 3
Search results for "North America"
Web Resource > Multi-use Website
University of North Texas Health Science Center.
Journal Article > Study
Description and evaluation of adaptations to the Global Trigger Tool to enhance value to adverse event reduction efforts.
Kennerly DA, Saldaña M, Kudyakov R, da Graca B, Nicewander D, Compton J. J Patient Saf. 2013;9:87-95.
The Institute for Healthcare Improvement's Global Trigger Tool is a widely used approach for detecting and monitoring safety hazards, but the accuracy of the tool has been criticized. Cases flagged by triggers also require more detailed chart reviews, which may not be feasible for institutions with limited resources. This study reports how one health system attempted to address these limitations of the Global Trigger Tool, with the goal of developing a sustainable mechanism for identifying adverse events (AEs), tracking rates of AEs over time, and providing sufficient detail to inform solutions. The article provides a detailed description of how the tool was adapted and implemented within existing resource constraints, information that may be helpful to other institutions needing to prioritize among multiple potential approaches for improving safety.
Journal Article > Review
Singer SJ, Vogus TJ. Annu Rev Public Health. 2013;34:373-396.
This review details a framework to help health care organizations develop, implement, and enhance safety culture.
Journal Article > Study
Patient safety incidents associated with obesity: a review of reports to the National Patient Safety Agency and recommendations for hospital practice.
Booth CM, Moore CE, Eddleston J, Sharman M, Atkinson D, Moore JA. Postgrad Med J. 2011;87:694-699.
The obesity epidemic is considered an urgent public health issue in Europe and the United States. Although morbidly obese patients are prone to a variety of medical issues, no study to date has evaluated patient safety risks in this population. This retrospective analysis of errors voluntarily reported to the United Kingdom's National Patient Safety Agency documents more than 380 errors and near misses in which obesity was considered a contributing factor. The majority of errors were partly attributable to inadequate equipment for caring for such patients, particularly in the surgical and critical care environments. Based on these data, the authors advocate for multidisciplinary approaches to systematizing care for morbidly obese patients. The challenges of caring for obese patients are discussed in an AHRQ WebM&M commentary, which examined a case of an ultimately fatal delayed diagnosis in a morbidly obese woman.
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.
Legislation/Regulation > Pennsylvania Legislation
General Assembly of Pennsylvania. SB968 (2007).
This bill requires that Pennsylvania hospitals and nursing homes implement an internal infection control plan and report hospital-acquired infections.