Narrow Results Clear All
- WebM&M Cases 2
Perspectives on Safety
- Interview 12
- Commentary 53
- Review 11
- Study 68
- Audiovisual 6
- Book/Report 24
- Legislation/Regulation 2
- Newspaper/Magazine Article 55
- Newsletter/Journal 1
- Special or Theme Issue 13
- Toolkit 2
- Web Resource 41
- Award 41
- Grant 19
- Meeting/Conference 2
- Press Release/Announcement 21
- Communication between Providers 12
- Culture of Safety 36
Education and Training
- Students 1
Error Reporting and Analysis
- Never Events 11
- Error Reporting 72
- Human Factors Engineering 18
Legal and Policy Approaches
- Regulation 34
- Logistical Approaches 8
- Policies and Operations 2
Quality Improvement Strategies
- Benchmarking 23
- Research Directions 4
- Specialization of Care 6
- Teamwork 12
- Clinical Information Systems 32
- Transparency and Accountability 9
- Alert fatigue 1
- Device-related Complications 9
- Diagnostic Errors 11
- Discontinuities, Gaps, and Hand-Off Problems 15
- Fatigue and Sleep Deprivation 3
- Identification Errors 5
- Medical Complications 61
- Medication Errors/Preventable Adverse Drug Events 25
- Nonsurgical Procedural Complications 1
- Overtreatment 2
- Psychological and Social Complications 5
- Surgical Complications 36
- Transfusion Complications 3
- Allied Health Services 1
- Internal Medicine 83
- Pediatrics 10
- Nursing 5
- Pharmacy 15
- Family Members and Caregivers 5
- Health Care Executives and Administrators 233
Health Care Providers
- Nurses 9
- Physicians 35
Non-Health Care Professionals
- Educators 12
- Media 5
- Patients 51
- Asia 2
- Australia and New Zealand 9
- Europe 10
- Canada 5
United States of America
United States Federal Government
- Department of Health and Human Services (HHS) 33
- United States Federal Government 38
Search results for "Incentives"
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.
Cases & Commentaries
- Spotlight Case
- Web M&M
Peter Lindenauer, MD, MSc; November 2006
A woman with end stage renal disease and heart disease on anticoagulation receives a pneumonia vaccination that causes a large hematoma.
Robeznieks A. Mod Healthc. October 16, 2006;36:41.
This article discusses the Leapfrog Group's first annual list of "Top Hospitals" (according to the group's quality standards) and the health care industry's response to the list and the measures used to create it.
Award > Award Recipient
The Joint Commission.
The Eisenberg Award honors individuals and organizations who have made vital accomplishments in improving patient safety and quality. The 2006 honorees are Dr. Donald Berwick, Dr. Jerry Gurwitz, Minnesota Alliance for Patient Safety, Pennsylvania Patient Safety Authority, and the Wichita Citywide Heart Care Collaborative.
Perspectives on Safety > Perspective
with commentary by Ashish K. Jha, MD, MPH, The Transformation of Patient Safety at the VA, September 2006
Five years after the landmark Crossing the Quality Chasm report by the Institute of Medicine (IOM), the quality and safety of health care in the United States remains far from ideal.(1) It is easy to feel pessimistic. Can health care organizations really...
The Commonwealth Fund Commission on a High Performance Health System. New York, NY: The Commonwealth Fund; August 2006.
This report calls for providing "safe, well-coordinated, accessible, and efficient" care through five key steps: expanding health insurance coverage, implementing evidence-based patient safety and quality interventions, increasing use of health information technology, public reporting of safety and quality measures, and rewarding achievement in quality through "pay-for-performance." The authors ascribe the current quality problems in the U.S. health care system to system failures, including misaligned payment incentives, inadequate motivation to challenge the status quo, inadequate information systems, duplicative regulatory systems, and an overemphasis on autonomy.
Web Resource > Multi-use Website
London, UK: The Health Foundation.
This program seeks to work with member acute care hospitals in the United Kingdom to build, sustain, and spread models of safety improvement developed during the Safer Patients Initiative.
Baltimore, MD: Centers for Medicare & Medicaid Services (CMS) Office of Public Affairs; May 18, 2006.
This fact sheet provides information regarding the Centers for Medicare and Medicaid Services' initiative to better understand and minimize never events.
San Francisco, CA: The Leapfrog Group; May 2, 2006.
This news release announces that 22 California hospitals have been recognized for their achievements in addressing The Leapfrog Group's standards of quality and safety.
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 > Commentary
Kellerman B. Harv Bus Rev. April 2006;84:72-81.
The author provides guidance for leaders on when to publicly apologize and how to do so.
Journal Article > Study
McCarthy D, Blumenthal D. Milbank Q. 2006;84:165-200.
This study shares the efforts of six different health care organizations in implementing interventions to improve patient safety. All of the organizations identified culture change as the most important factor in promoting safety, though the mechanisms to achieve such change differed. The authors provide a contextual background of safety culture, including definitions, attributes, and strategies to approach the issue, and present a detailed account of each case study. They point out that creating a desired culture of safety may be both foundational to safety efforts and also very challenging to accomplish. The shared stories offer a practical perspective regarding the issues that face most organizations committed to improving patient safety.
ISMP Medication Safety Alert! Acute Care Edition. December 15, 2005;10:1-3.
This award cycle recognizes the activities of 11 individuals and organizations working to improve medication safety in 2005.
Edmonton, AB: Canadian Patient Safety Institute; December 2, 2005.
This news release announces the selection of 28 research and demonstration projects eligible for funding from the Canadian Patient Safety Institute research initiative.
Journal Article > Commentary
Rubin GL, Leeder SR. Med J Aust. 2005;183:529-531.
The authors assert that enhancements in measuring safety, financial incentives, education, and management would improve patient safety in Australia.
Journal Article > Study
Cutler DM, Feldman NE, Horwitz JR. Health Aff (Millwood). 2005;24:1654-1663.
This study discovered that implementation of computerized physician order entry (CPOE) systems is a greater reflection of hospital ownership and teaching status than hospital profitability. Using Leapfrog survey data derived from their efforts to reward CPOE adoption, investigators present findings from hospitals with varying degrees of operational CPOE systems. While many have argued that limitation in resources prevents wider implementation, these findings counter those explanations. Interestingly, government hospitals represented the most likely adopters and for-profit organizations the least likely, adding to the notion that these systems are not intended to provide significant profits. Findings suggest that other factors, such as caring for the sickest patients or political interests in safety, may partly explain the results. The authors express concern that less than 5% of hospitals are in compliance with CPOE standards and that changes in the reimbursement environment through federal initiatives may provide necessary stimulus.
Glabman M. Trustee. October 2005;58:29-32.
This article discusses several strategies implemented by hospitals to improve the legibility of physicians' medication orders.
Journal Article > Study
Hospital implementation of computerized provider order entry systems: results from the 2003 Leapfrog Group quality and safety survey.
Hillman JM, Given RS. J Healthc Inf Manag. Fall 2005;19:55-65.
The Leapfrog Group's widely recognized efforts to promote patient safety include an initiative to mandate implementation of computerized provider order entry (CPOE) systems at hospitals across the country. This survey of more than 840 participating hospitals demonstrated that while only 3.7% use fully implemented systems, 92% shared plans for at least partial implementation of a CPOE system. Discussion includes analysis of the organizational and financial characteristics of participating hospitals, how hospitals with full implementation differ from those with partial efforts, and various predictors of implementation. Few statistically significant organizational factors were correlated to the variability in CPOE implementation, including profitability, bed size, or penetration of health care maintenance organizations (HMOs). The authors suggest that ongoing changes to financial incentives in health care, such as pay-for-performance, will continue to promote adoption of these technologies that support patient safety.
The Joint Commission.
The Eisenberg Award honors individuals and organizations who have made vital accomplishments in improving patient and quality. The 2005 honorees are Audrey Nelson, PhD, RN; Maryland Patient Safety Center; Meridian Health, New Jersey; and Sentara Healthcare, Virginia and North Carolina. The awards were presented at the National Quality Forum's Annual Meeting on Thursday, October 6, in Washington, DC.
The John D. and Catherine T. MacArthur Foundation. September 20, 2005.
Michael Cohen, President of the Institute for Safe Medication Practices, has focused his career on preventing medical errors with innovative and elegant solutions. The MacArthur Foundation has selected him as a 2005 Fellow and recipient of a $500,000 "genius grant."