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Search results for "State Governments and Agencies"
- Safety Scientists
- State Governments and Agencies
Web Resource > Government Resource
Center for Health Information and Analysis.
The Betsy Lehman Center is a nonregulatory Massachusetts state agency named for Betsy Lehman, the Boston Globe columnist who died due to an inadvertent chemotherapy overdose. The Center works to support a statewide program coordinating health care organization and provider efforts to reduce medical errors, enabling patients to participate in safety improvement, and disseminating information about best practices.
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.
Rensselaer, NY: Healthcare Association of New York State; October 2013.
This publication assessed 10 widely disseminated hospital report cards by criteria including transparency of methodology, evidence-based measures, and data quality. While inconsistent methods across reports hindered direct comparisons, a few reports received high marks.
Journal Article > Commentary
Should medical malpractice prevention be considered separately or as an integral part of comprehensive health care safety improvement?
Enbom JA. Am J Obstet Gynecol. 2013;208:495-498.
Exploring the relationship between liability payments and patient safety, this commentary recommends that the concepts be combined to inform and drive improvement.
Journal Article > Study
Shahian DM, Wolf RE, Iezzoni LI, Kirle L, Normand SL. N Engl J Med. 2010;363:2530-2539.
Hospital-wide mortality rates are widely used as a marker of health care quality, but it remains unclear how to most accurately measure them. In this classic study, investigators provided standard hospital discharge data to four vendors who independently calculated hospital mortality rates. These methods produced varying rates of hospital mortality, and classification of hospitals as either higher or lower than average differed depending on the estimation method. These findings demonstrate that in-hospital mortality remains difficult to estimate and underscore the need for caution in considering it a marker of hospital care quality.
PA-PSRS Patient Saf Advis. March 2008;5(suppl rev):1-50.
This failure mode and effects analysis (FMEA) explores factors contributing to near miss and adverse events related to alarm response and provides strategies to prevent monitoring failures.
Legislation/Regulation > Congressional Testimony
Hearings before the House Insurance Committee of the Pennsylvania General Assembly. (April 22, 2004) (statement of James R. Combes, MD, senior medical advisor, HAP).
This statement introduces the Pennsylvania Patient Safety Reporting System (PA-PSRS), a statewide reporting initiative.