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- Governmental Reporting
- Root Cause Analysis
St. Paul, MN: Minnesota Department of Health; March 2019.
The National Quality Forum has defined 29 never events—patient safety problems that should never occur, such as wrong-site surgery and patient falls. Since 2003, Minnesota hospitals have been required to report such incidents. The 2018 report summarizes information about 384 adverse events that were reported and found pressure ulcers and invasive procedure events increased, while fall-related deaths decreased. Reports from previous years are also available.
Colburn D. The Oregonian. February 1, 2006:B1.
This article reports on the launch of Oregon's statewide voluntary incident reporting program to track medical error.
Gulliver D. Sarasota Herald Tribune. November 7, 2006:BS1.
This article reports on the death of a restrained patient and outlines the factors affecting the subsequent reporting of the event.