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Search results for "Hospitals"
Manchester, UK: General Medical Council; June 2019.
Finding the appropriate balance between assigning criminality and accountability for tragic preventable patient harm is difficult. Summarizing a high-profile case in the United Kingdom that involved the death of a pediatric patient, misdiagnosis, and a senior pediatric trainee, this report explores elements of the criminality and accountability debate across the system and discusses policy, judicial, and individual components of a fair and just response to adverse events to keep organizations, clinicians, and patients safe.
Child Health Patient Safety Organization. Washington, DC: Children's Hospital Association; 2017.
London, UK: Parliamentary and Health Service Ombudsman; July 18, 2016. ISBN: 9781474135764.
The National Health Service (NHS) has a history of sharing analyses of problems in its system. Summarizing an NHS investigation into the death of a 3-year-old boy, this report highlights the need to improve organizational culture, complaint follow-up, and transparency to reduce opportunities for similar incidents.
Communicating Radiation Risks in Paediatric Imaging: Information to Support Healthcare Discussions About Benefit and Risk.
Geneva, Switzerland: World Health Organization; 2016. ISBN: 9789241510349.
Overuse of diagnostic imaging poses patient safety hazards, particularly for children. This report reviews techniques clinicians can use to discuss risks associated with using radiologic procedures with parents of pediatric patients. The publication includes answers to common questions about various types of tests and tips for enhancing conversations with parents.
Addressing the Global Shortages of Medicines, and the Safety and Accessibility of Children's Medication.
Geneva, Switzerland: World Health Organization; 2015.
Drug shortages have the ability to affect the patient safety in emergency departments, oncology services, and pediatrics. This report discusses the consequences of drug shortages, approaches different countries are taking to reduce their occurrence, and strategies such as proactive identification of potential supply limitations and collective agreements to manage shortages.
Visser SN, Zablotsky B, Holbrook JR, Danielson ML, Bitsko RH. Natl Health Stat Report. 2015;(81):1-8.
This survey of parents of children with attention-deficit/hyperactivity disorder examined how this diagnosis was established. There was variation in the diagnostic process, including testing methods and types of practitioners involved (primary care physician, psychologist, psychiatrist). These results demonstrate the inherent challenge of diagnosing a heterogeneous condition even when diagnostic guidelines and criteria exist.
Washington, DC: Leapfrog Group; March 2015.
National hospital quality reports aim to provide benchmarks on safety and other quality measures, though questions remain regarding their universal applicability to gauge improvement. This analysis of the 2014 Leapfrog Hospital Survey results found that while the majority of hospitals employed computerized provider order entry (CPOE), not all systems provided appropriate warnings to prevent potentially harmful orders, suggesting CPOE systems still need improvement to augment safety.
Reed K, May R. Golden, CO: Health Grades, Inc; 2010.
This report analyzed Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicator data from 2006–2008 to identify pediatric patient safety incidence rates.
Krug SE, ed. Oak Brook, IL: Joint Commission Resources and the American Academy of Pediatrics; 2010. ISBN: 9781599402123.
This book presents tools, examples, strategies, and guidance to help health care leaders and front line personnel provide safe emergency care to pediatric patients.
King S. New York, NY: Atlantic Monthly Press; 2009. ISBN: 9780802119209.
This memoir shares the story of Sorrel King's crusade to make medical care safer. Sorrel King is the mother of Josie King, who died tragically in 2001 at age 18 months because of medical errors during a hospitalization at Johns Hopkins Hospital. She has subsequently become one of the nation's foremost patient advocates for safety, forming an influential foundation (the Josie King Foundation) and partnering with Johns Hopkins to promote the field of patient safety around the world.
London, UK: National Patient Safety Agency; 2009. ISBN: 978906624071.
Analyzing research and more than 900,000 incident reports submitted to the National Patient Safety Agency, this report identifies adverse events affecting children and emphasizes actions for stakeholders to enhance safety for pediatric patients in the United Kingdom.
Shekelle PG, Morton SC, Keeler EB. Evidence Report/Technology Assessment No. 132 (Prepared by the Southern California Evidence-based Practice Center under Contract No. 290-02-0003.) Rockville, MD: Agency for Healthcare Research and Quality; April 2006. AHRQ Publication No. 06-E006.
The authors reviewed the literature on health information technology (HIT). They conclude that HIT may reduce pediatric medication errors, have the potential to improve safety and quality, and require more study to fully articulate the cost and implementation issues.
Learning from Bristol: The Report of the Public Inquiry into Children's Heart Surgery at the Bristol Royal Infirmary 1984–1995.
London, England: The Stationery Office; July 2001.
In June 1998, the Secretary for Health announced to Parliament the organization of a formal Inquiry into children's heart surgery at the Bristol Royal Infirmary between 1984 and 1995. Their objectives included understanding what happened in Bristol, assessing the quality of care and system failures that contributed to deaths, and generating lessons that could be learned for the entire National Health Service (NHS) in the United Kingdom. The inquiry was independent and not held as a legal proceeding, but provided a comprehensive investigation with interviews, expert panels, and a goal of driving improvement efforts. Section one of the report outlines pediatric cardiac surgical services in Bristol while section two focuses on recommendations to ensure high quality care across the NHS. Several publications resulted from the learnings of the Bristol inquiry, including a discussion of cultural entrapment and lessons for quality improvement.
The Report of the Manitoba Pediatric Cardiac Surgery Inquest: An Inquiry into Twelve Deaths at the Winnipeg Health Sciences Center in 1994.
Sinclar M. Provincial Court of Manitoba, CA.
A 3-year review investigating a series of deaths from a pediatric cardiac unit revealed flaws in the recruitment process, quality assurance mechanisms, treatment of nurses, staffing, and lines of authority. The report offers recommendations for necessary quality improvements.