Narrow Results Clear All
- Communication Improvement 6
- Culture of Safety 11
- Education and Training 9
- Error Reporting and Analysis 28
- Human Factors Engineering 17
- Legal and Policy Approaches 3
- Quality Improvement Strategies 17
- Research Directions 2
- Teamwork 5
- Technologic Approaches 8
- Device-related Complications 1
- Diagnostic Errors 2
- Discontinuities, Gaps, and Hand-Off Problems 4
- Drug shortages 1
- Identification Errors 1
- Interruptions and distractions 1
- Medical Complications 4
- Medication Safety 8
- Surgical Complications 1
- Health Care Executives and Administrators 62
Health Care Providers
- Nurses 2
Non-Health Care Professionals
- Safety Scientists
- Patients 2
- Europe 22
- Canada 2
- United States of America 40
Search results for "Safety Scientists"
- Safety Scientists
Pedersen KZ. London, United Kingdom: Palgrave Macmillan; 2018. ISBN: 9781137537850.
The book suggests that though a systems orientation to safety improvement is the correct approach, it can be complex and difficult to operationalize. The author explores the unintended influences of blame-free methodologies, challenges the belief that fixing the system will prevent all error, and cautions health care to moderate patient engagement efforts.
Washington, DC: National Quality Forum; 2016.
The value of current measures to track patient safety has been called into question. This technical report provides information about a consensus-driven initiative to evaluate the reliability of existing patient safety measures in tracking and assessing safety in hospitals, across various populations and settings. The related website offers resources related to the project history.
Office of Health Care Quality. Baltimore, MD: Maryland Department of Health and Mental Hygiene; 2018.
This annual report summarizes never events in Maryland hospitals over the previous year. From July 2016--June 2017, reported patient falls and pressure ulcers increased. The authors recommend several corrective actions to build on training and policy changes to guide improvement work, including improving use of hospital data to proactively manage risk and engaging hospital and departmental leaders in root cause analysis.
Spath PL, ed. San Francisco, CA: Jossey-Bass; 2011. ISBN: 9780470502402.
Error Reduction in Health Care remains one of the few comprehensive textbooks in patient safety. This updated edition covers key concepts in safety, beginning with the systems approach and the role of human factors engineering in patient safety. Also included are sections on measurement and interpretation of safety data, error analysis techniques, and approaches to improving patient safety (e.g., teamwork training and developing a culture of safety). The book's chapters are authored by experts in the field and strike a balance between background theory and practical approaches to reducing preventable adverse events.
The Financial and Human Cost of Medical Error... and How Massachusetts Can Lead the Way on Patient Safety.
Boston, MA: Betsy Lehman Center for Patient Safety; June 2019.
The Betsy Lehman Center is a nonregulatory Massachusetts state agency that works to coordinate provider, patient, and policy maker efforts to reduce medical errors. This report describes the results of two studies conducted by the Center and includes a retrospective analysis of insurance claims associated with preventable medical errors. Investigators identified nearly 62,000 errors and calculated excess claim costs due to medical errors of more than $617 million over a 12-month period. The Center also conducted a patient survey exploring harms from medical errors. Respondents reported loss of trust and suboptimal disclosure practices around medical errors. These results collectively convey ongoing, large-scale safety gaps in health care delivery. A past PSNet perspective discussed the tragic error involving Betsy Lehman, who died due to an inadvertent overdose of chemotherapy while receiving treatment for breast cancer at the Dana-Farber Cancer Institute.
Dallas, TX: Facilities Guidelines Institute; 2018.
These updated guidelines include design changes, such as the adoption of private rooms to reduce medical error, interruptions, and hospital-acquired infections. The 2018 edition was developed as a 3-volume set covering hospitals, outpatient facilities, and residential health, care, and support facilities. Each provides information on design elements that enhance safety. The material also includes risk assessments to identify space concerns that could lead to unsafe conditions.
Graban M. Boca Raton, FL: Productivity Press; 2016. ISBN: 9781498743259.
Lean methodology focuses on establishing a culture that supports employee safety and drives process improvement. This book provides information about Lean and how to implement such concepts to integrate quality and safety behaviors in health care delivery. One chapter focuses on the use of root cause problem-solving and error prevention. The author spoke about applying Lean in hospitals in a previous PSNet interview .
Developing and Testing the Health Care Safety Hotline: A Prototype Consumer Reporting System for Patient Safety Events. Final Report.
Schneider EC, Ridgely MS, Quigley DD, et al. Rockville, MD: Agency for Healthcare Research and Quality; May 2016. AHRQ Publication No. 16-0027-EF.
Patient safety hotlines are a strategy to improve reporting and collecting of comments from patients, clinicians, and staff to notify hospitals about problems in care processes. This report describes the development of one such program, the Health Care Safety Hotline. Drawing from design and testing of the hotline, the authors conclude that more research is needed to understand why patients were more likely to access reports than contribute to them and how to simplify goals for the tool to enhance its usefulness.
Rockville, MD: Center for Drug Evaluation and Research, US Food and Drug Administration; April 2016.
The Clinical Center Working Group Report to the Advisory Committee to the Director, National Institutes of Health. Bethesda, MD; National Institutes of Health; April 2016.
This publication outlines system problems at a large research institution that could compromise patient safety, including supervisors' failure to address staff-reported concerns, prioritization of research productivity over safety, insufficient processes for reporting and tracking problems, and fragmented accountability for ensuring quality and safety at the institution.
Boston, MA: Harvard School of Public Health; December 2014.
This statewide public telephone survey in Massachusetts found that more than 20% of respondents experienced a medical error in the prior 5 years, and more than half of these incidents resulted in harm. Prior patient surveys have brought to light previously unrecognized safety problems, although discrepancies have been shown to exist between patient reports and other methods for detecting adverse events. Most respondents attributed adverse events to individual physicians and nurses rather than health systems, underscoring the challenge of conveying blame-free culture and systems approaches to the public. Diagnostic errors were the most common type of error reported. About half of patients who experienced medical errors reported the incident to a clinician, hospital, or official agency. Most patients did not look for safety or quality information in choosing a physician or hospital, and only a third of respondents view patient safety as a serious problem for the state. Importantly, prior to being given an explanation, less than half of respondents understood the term "medical error." These findings emphasize the divide between the high prevalence of safety hazards and the lack of public awareness of patient safety efforts and policy.
Dixon-Woods M, Martin G, Tarrant C, et al. London, UK: Health Foundation; December 2014.
This report discusses the results of a United Kingdom initiative exploring how safety strategies from high-risk industries can inform the redesign of processes and improvement work in health care organizations in order to address underlying system problems. The material uses the case study format to translate the findings into practical recommendations for application in the field.
Oakbrook Terrace, IL: The Joint Commission; November 2014.
This Joint Commission annual report shows continued improvements in quality of care in hospitals across the United States. This year's list of Top Performers included a record 1224 hospitals, representing nearly 37% of all reporting Joint Commission-accredited hospitals. Even as The Joint Commission has added new accountability measures over the past few years for stroke care, venous thromboembolism, perinatal care, and immunizations, the number of hospitals reaching at least a 95% composite accountability score has more than tripled in the past 4 years. Major gains were found this year in the quality of perinatal care, children's asthma, venous thromboembolism, and inpatient psychiatric services. Heart attack care now has a composite score of 99%.
Manchester, UK: General Medical Council; November 2014.
Waterson P, ed. London, UK: Ashgate; 2014. ISBN: 9781409448143.
London, UK: Frontier Economics Ltd; October 2014.
This report provides an overview of evidence on preventable adverse events in the National Health Service and estimates that health care–acquired patient harm results in £1 to £2.5 billion in extra costs annually.
Bencheikh SR, Cousins D, Benabdallah G, et al. Geneva, Switzerland: World Health Organization; October 2014. ISBN: 9789241507943.
Leys C, Toft B. London, UK: Centre for Health and the Public Interest; August 2014.
This report discusses issues with staffing, equipment, and documentation that contributed to patient harm in private hospitals in the United Kingdom from 2010 to 2014. The authors explain how limited reporting requirements and lack of reliable data hinders patients' ability to compare the care provided by private hospitals with National Health System hospitals. They also outline recommendations to augment data collection and transparency in private hospitals.
Golden, CO: HealthGrades, Inc.; June 9, 2014.
Analyzing Medicare data from 2010 through 2012, this report discusses hospital efforts to prevent patient harm and estimates that nearly 267,000 preventable patient safety events such as pressure ulcers and catheter-related bloodstream infections occurred during this period. In 2014, 381 hospitals received the Healthgrades Patient Safety Excellence Award.
Zipperer L, ed. London, UK: Gower Publishing; 2014. ISBN: 9781409438571.