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Search results for "Long-Term Care"
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.
Washington, DC: National Quality Forum; September 2009.
This announcement provides background on the proposed 2010 effort to revise and expand the National Quality Forum list of never events.
Journal Article > Study
Boyer R, McPherson ML, Deshpande G, Smith SW. Am J Hosp Palliat Care. 2009;26:361-367.
Patients enrolled in hospice care are generally elderly and may use high-risk medications, such as opioids and sedatives. These factors have been associated with serious medication errors in prior studies. However, little is known about medication errors in hospice patients. In this study conducted in two hospice organizations, clinical personnel received an educational seminar designed to encourage voluntary reporting of adverse drug events. The intervention resulted in improved understanding of medication errors and increased error reporting (at one of the two sites). Prior studies have also successfully increased error reporting rates but, as a recent commentary notes, incident reporting itself may not improve safety unless reported incidents are rigorously analyzed and followed up.
Santell JP. Mater Manage Health Care. December 19, 2006;15:26-28, 30.
The author discusses the role that human error plays in the failure of technological solutions employed to minimize medical mistakes.
Bailey B, Sevrens Lyons J. The Mercury News. November 27, 2005.
This article reports on several errors that occurred at hospitals in California and discusses the state's regulatory system.
Zaidi K, Curry PD Jr, Becker SC. Pharmaceutical Technology. November 2, 2005;29:102-103.
This article reports on recommendations developed by United States Pharmacopeia (USP) to improve the safety of using medical gas, including revisions to USP monographs.