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- Communication Improvement 2
- Education and Training 2
- Error Reporting and Analysis 2
- Human Factors Engineering 1
- Legal and Policy Approaches 1
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- Technologic Approaches 1
- Device-related Complications 1
- Medical Complications 1
- Medication Safety 2
- Psychological and Social Complications 1
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World Innovation Summit for Health 2015. Doha, Qatar: Qatar Foundation; February 2015.
This conference focused on persisting barriers to patient safety worldwide and recommended strategies to achieve lasting improvement, including dedication to systems engineering, patient-centeredness, and process integration. The session summarized findings of a report developed for the event, Transforming Patient Safety: a Sector-wide Systems Approach. The proceedings collection includes the full text of the report, video of the panel, and podcasts with Margaret Murphy, Dr. Mary Dixon-Woods, Dr. Peter Pronovost, and other participants.
Oakbrook Terrace, IL: Joint Commission Center for Transforming Health Care. Chicago, IL: American College of Surgeons. November 2012.
Some of the most prominent successes in the patient safety field have been achieved in preventing health care–associated infections. Sponsored by The Joint Commission Center for Transforming Healthcare and the American College of Surgeons, this effort used rigorous quality improvement methodology and a collaborative approach across seven participating hospitals to tackle the problem of surgical site infections (SSIs) in patients undergoing colorectal surgery. The project was a remarkable success, achieving a 32% reduction in SSIs during the study period. The Center for Transforming Healthcare is also sponsoring efforts to prevent wrong-site surgery and improve hand hygiene and handoff communications.
Poll: Many Sick Americans Experience Significant Financial Problems and Report Their Care is not Well-Managed.
Princeton, NJ: Robert Wood Johnson Foundation, National Public Radio, and the Harvard School of Public Health. May 21, 2012.
This report describes findings from a poll that investigated how cost of care and health insurance affect patients' experiences of health care quality and safety in the United States.
Fillo KT. Bureau of Health Care Safety and Quality, Department of Public Health. Boston, MA: Commonwealth of Massachusetts; July 2018.
This report compiles patient safety data documented by Massachusetts hospitals. The latest numbers represent a modest decrease in serious reportable events recorded in acute care hospitals, from 1012 the previous year to 922. This presentation also includes events from ambulatory surgery centers. Previous years reports are also available.
World Alliance for Patient Safety. Geneva, Switzerland: World Health Organization; 2008.
Through a discussion of a vincristine administration error, this booklet and video illustrate how system weaknesses can contribute to failure.
Different roles, same goal: risk and quality management partnering for patient safety. By the ASHRM Monographs Task Force.
Perry DG, Bokar V. J Healthc Risk Manag. 2007:27;17-25.
This monograph describes how a coordinated effort between hospital risk management and quality improvement teams can enhance patient safety.
Blumenthal D, DesRoches C, Donelan K, et al. Washington, DC: Robert Wood Johnson Foundation; 2006.
This report shares the results of a study on the electronic health record (EHR) and barriers to its adoption. The investigators found that EHR systems are not widely adopted and make recommendations for improving implementation.
Kaiser Family Foundation, Agency for Healthcare Research and Quality, and the Harvard School of Public Health; November 2004.
Five years after the Institute of Medicine's landmark report on medical errors, this survey assessed Americans' perceptions about the quality of health care, their awareness and reported usage of information in making their health care choices, and their experiences with their health care providers. A summary of the findings is provided, as well as a Webcast featuring experts discussing the survey results.