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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.
Web Resource > Multi-use Website
American Society of Health-System Pharmacists.
This Web site provides a selection of materials and discussion groups to help hospital-based pharmacists improve medication safety.
Tools/Toolkit > Multi-use Website
Portland, ME: National Academy for State Health Policy.
This online toolkit provides sample documents, policies, and Web site links related to the 27 states that have implemented adverse event reporting initiatives.
Washington, DC: United States Government Accountability Office; June 2006. Publication GAO-06-416.
This government report found that the clinical laboratory survey process is flawed, allowing safety requirements to be bypassed.
Audiovisual > Audiovisual Presentation
Washington, DC: Alliance for Health Reform; April 7, 2006.
This Webcast presents a panel discussion on the development of patient safety organizations as stipulated by the Patient Safety and Quality Improvement Act of 2005 and other developments in the safety movement. Panelists include several patient safety leaders, including Agency for Healthcare and Research Quality (AHRQ) director, Carolyn Clancy.
Nursing Homes: Despite Increased Oversight, Challenges Remain in Ensuring High-Quality Care and Resident Safety.
Washington, DC: United States Government Accountability Office; 2005. Report No. GAO-06-117.
This report shares findings from a 5-year review of nursing home quality and safety, which revealed inconsistencies in state surveys that affect the government's ability to adequately address problems in care.