Narrow Results Clear All
- WebM&M Cases 1
- Perspectives on Safety 7
- Review 1
- Study 10
- Audiovisual 4
- Book/Report 10
- Legislation/Regulation 1
- Newspaper/Magazine Article 22
- Newsletter/Journal 1
- Web Resource 8
- Award 1
- Press Release/Announcement 2
- Communication Improvement 5
- Culture of Safety 5
- Education and Training 8
Error Reporting and Analysis
- Error Reporting 21
- Human Factors Engineering 8
Legal and Policy Approaches
- Regulation 11
Quality Improvement Strategies
- Benchmarking 14
- Research Directions 1
- Specialization of Care 2
- Technologic Approaches 6
- Transparency and Accountability 8
- Device-related Complications 2
- Diagnostic Errors 1
- Discontinuities, Gaps, and Hand-Off Problems 2
- Identification Errors 2
- Medical Complications 6
- Medication Errors/Preventable Adverse Drug Events 7
- Nonsurgical Procedural Complications 1
- Psychological and Social Complications 1
- Surgical Complications 10
- Medicine 41
- Nursing 2
- Pharmacy 2
- Family Members and Caregivers 5
- Health Care Executives and Administrators 41
Health Care Providers
- Nurses 1
- Non-Health Care Professionals 23
- Patients 22
- Australia and New Zealand 2
- Europe 1
- Canada 1
Search results for "Public Reporting"
- Public Reporting
Gabler E. New York Times. May 31, 2019.
Pediatric cardiac surgery is highly technical and risky. This newspaper article reports on a poorly performing pediatric cardiac surgery program, concerns raised by staff, and insufficient response from organizational leadership. Lack of data transparency, insufficient resources, and limited program capabilities to support a complex program contributed to poor outcomes for pediatric patients.
Lives Lost, Lives Saved: An Updated Comparative Analysis of Avoidable Deaths at Hospitals Graded by The Leapfrog Group.
Austin M, Derk J. Baltimore, MD: Armstrong Institute for Patient Safety and Quality, and Johns Hopkins Medicine; May 2019.
Measures help track gaps in process and evidence of safety improvements. This white paper examines the performance of hospitals receiving Hospital Safety Grades and the relationship between high-level recognition and preventable harm. The report estimates that a substantial number of lives could have been saved if performance metrics had been met, but concludes that even high-performing hospitals exhibit areas in need of improvement.
Jewett C. Kaiser Health News. May 3, 2019.
Transparency has been heralded as a cornerstone to improvement in health care. This news article reports on a government alternative summary reporting program that allowed medical device makers to conceal safety events and malfunction reports associated with medical devices. A new program that expands access to information about device-related failures will be put in place.
Journal Article > Study
Schlesinger MJ, Rybowski L, Shaller D, et al. Health Aff (Millwood). 2019;38:374-382.
This study used survey data collected in 2010, 2014, and 2015 to examine public perceptions of health care quality information over time. Investigators found that the public was more likely to be aware of quality information in 2014 and 2015 compared to 2010. Patients with higher educational attainment and patients from racial and ethnic minority populations were more likely to report awareness of health care quality. They conclude that this growing awareness provides an opportunity to enhance patient engagement.
Journal Article > Commentary
Easter K, Tamburri LM. Crit Care Nurse. 2018;38:58-66.
Public reporting of safety and quality deficits is a key component of health care transparency. This commentary introduces terminology, tools, and skill development tactics to enhance nurses' use and application of outcome data to address problems. Plan-do-study-act cycles illustrate evaluation and quality improvement actions nurses can use on the front line to test and refine improvements.
Journal Article > Study
Associations between hospital characteristics, measure reporting, and the Centers for Medicare & Medicaid Services overall hospital quality star ratings.
DeLancey JO, Softcheck J, Chung JW, Barnard C, Dahlke AR, Bilimoria KY. JAMA. 2017;317:2015-2017.
The Centers for Medicare and Medicaid Services (CMS) recently implemented the star rating system for hospitals as an overall measure of quality and safety. Although studies have found a correlation between the star ratings and clinical outcomes, this study found that high star ratings were more likely to be given to specialty or critical access hospitals. These hospitals are exempt from some of the CMS quality measure reporting requirements, and thus they did not report the same data as lower-rated hospitals. Other studies have also called into question the methodology behind the star rating system.
Ornstein C. Health Shots. National Public Radio and ProPublica. April 18, 2017.
Summary data about serious errors in hospitals are available, but often details of accreditation investigation findings are not accessible to the public. This news article reports on efforts by the Centers for Medicare and Medicaid Services to make this information publicly available to augment transparency and enhance health care safety.
Journal Article > Commentary
Moffatt-Bruce SD, Ferdinand FD, Fann JI. Ann Thorac Surg. 2016;102:358-362.
Although error disclosure is increasingly encouraged in health care, challenges to achieving transparency include liability and risk considerations, particularly for surgeons. This commentary describes the experiences of two health care systems that have implemented approaches to support transparent disclosure of medical errors.
Ginsburg M, Glasmire K. Oakland, CA: California HealthCare Foundation; April 2011.
Examining consumers' opinions on health care quality and safety, this report offers recommendations for hospitals to prioritize improvement efforts.
Web Resource > Government Resource
Agency for Healthcare Research and Quality.
This Web site provides tools to help organizations create and distribute quality of care reports to consumers.
Allen M. Washington Monthly. March/April 2011.
This magazine article reports on medical errors in the United States health care system and discusses transparency as a tactic to improve patient safety.
Bogdanich W, Rebelo K. New York Times. December 28, 2010;A1.
This article explores inaccuracy of dosage, lack of protocol adherence, and absence of transparency as trends that hinder learning from radiological adverse events.
Leape LL. Perspect Health Reform. New York, NY: The Commonwealth Fund; March 17, 2010.
Of three approaches to enhancing patient safety—regulation/accreditation, financial incentives, and public reporting—this perspective, written by the father of the modern patient safety movement, details how public reporting holds the most potential to stimulate improvement.
Wright S. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; January 5, 2010. Report No. OEI-06-09-00360.
Kauffman M, Altimari D. The Hartford Courant. November 15, 2009;Final:A1.
This newspaper article reports that a Connecticut law intended to make hospital errors more transparent has had the opposite effect by making it easier for hospitals to limit publicly available information on adverse events.
Journal Article > Commentary
Pronovost PJ, Goeschel CA, Marsteller JA, Sexton JB, Pham JC, Berenholtz SM. Circulation. 2009;119:330-337.
This article proposes a framework to further patient safety research and improvement by clarifying the clinical and policy domains that link to a safety scorecard.
Journal Article > Review
Systematic review: the evidence that publishing patient care performance data improves quality of care.
Fung CH, Lim YW, Mattke S, Damberg C, Shekelle PG. Ann Intern Med. 2008;148:111-123.
This review examined how publicly reported performance data affect quality of care and found that, although releasing such data stimulates quality improvement activities, the impact on clinical outcomes remains unclear.
Collins LM. Deseret Morning News. July 8, 2007;A1.
This article reports on Utah health officials' recent efforts to mandate error reporting, make that information open to the public, and use the data to improve patient safety.
Perspectives on Safety > Perspective
with commentary by Jill Rosenthal, MPH, State Error Reporting Systems, June 2007
Seven years ago, the Institute of Medicine (IOM) called on states to create mandatory reporting systems as part of a strategy to identify and learn about medical errors and ultimately to improve patient safety. Since then, many states have responded by creating or improving reporting systems to collect information about hospital-based adverse events. These systems can provide states with an opportunity to strengthen their facility oversight functions, safeguard the public, and partner with providers to improve health care quality.
Perspectives on Safety > Interview
State Error Reporting Systems, June 2007
Diane Rydrych, MA, is Assistant Director of the Division of Health Policy at the Minnesota Department of Health, where she oversees their successful and influential adverse health events reporting system. We asked her to speak with us about the Minnesota initiative and some of the broader lessons for state error reporting systems.