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- Communication Improvement 7
- Culture of Safety 1
- Education and Training 4
- Error Reporting and Analysis 5
- Human Factors Engineering 3
- Legal and Policy Approaches 3
- Logistical Approaches 2
- Quality Improvement Strategies 4
- Clinical Information Systems 2
- Diagnostic Errors 1
- Discontinuities, Gaps, and Hand-Off Problems 2
- Identification Errors 1
- Interruptions and distractions 1
- Medical Complications 2
- Medication Safety 5
- Nonsurgical Procedural Complications 1
- Psychological and Social Complications 1
- Surgical Complications 2
Search results for "State Governments and Agencies"
- Latent Errors
- State Governments and Agencies
Journal Article > Study
Defining minimum necessary anticoagulation-related communication at discharge: Consensus of the Care Transitions Task Force of the New York State Anticoagulation Coalition.
Triller D, Myrka A, Gassler J, et al. Jt Comm J Qual Patient Saf. 2018;44:630-640.
Patients prescribed high-risk medications, including anticoagulants, are at increased risk for adverse drug events and may be particularly vulnerable during care transitions. This study describes how a multidisciplinary panel of anticoagulation experts used an iterative consensus-building process to determine what information should be communicated to relevant providers for all patients on anticoagulation undergoing a transition in care.
Hewitt M, Hernandez LM; Roundtable on Health Literacy, Board on Population Health and Public Health Practice, Institute of Medicine. Washington, DC: National Academies Press; 2014. ISBN: 9780309303651.
Health literacy can affect patients' ability to understand directions, ask good questions, and participate in care. Framing health literacy as a public health challenge, this report describes efforts to address it in three states and explores implementation and research to improve it across the United States.
Feil M. PA-PSRS Patient Saf Advis. June 2014;11:45-52.
Operating rooms are complex environments with particular risks regarding interruptions and distractions. This article draws from data reported to the Patient Safety Authority to explore how distractions affect surgeons and other team members. The author reviews strategies to limit distractions, including applying sterile cockpit principles, performing preoperative briefings, and utilizing checklists.
Munn J. PA-PSRS Patient Saf Advis. March 2014;11:23-29.
Patients are increasingly being asked to assume a role in ensuring their own safety. This report explores patients' adoption of practices meant to help improve their safety and found that 8 of the 10 suggested tactics are actively used by health care consumers in Pennsylvania.
Sparnon E. PA-PSRS Patient Saf Advis. September 2013;10:92-95.
Analyzing data submitted to the Pennsylvania Patient Safety Reporting System, this article reviews the unintended consequences of automated default values, including errors in the electronic medical record and medication administration delays.
Harrisburg, PA: Patient Safety Authority; May 2019.
This report summarizes patient safety improvement work in the state of Pennsylvania and reviews the 2018 activities of the Patient Safety Authority, including the launch of the Center of Excellence for Improving Diagnosis, outreach programs, liaison efforts, and the convening of the first patient safety conference for the state.
PA-PSRS Patient Saf Advis. September 2010;7:76-86.
Analyzing reports of diagnostic errors, this article discusses common causes and provides suggestions for physicians and patients to prevent such events.
Special or Theme Issue
PA-PSRS Patient Saf Advis. December 2009;6(suppl 1):1-32.
Articles in this supplement draw from labor, delivery, and obstetric safety reports to provide insights for safe practice in obstetrics.
PA-PSRS Patient Saf Advis. December 2009;6:109-114.
This article discusses adverse incidents submitted to the Pennsylvania reporting system involving neuromuscular blocking agents and shares strategies to minimize errors with this type of high-alert drug.
PA-PSRS Patient Saf Advis. September 2008;5:75-80.
This article analyzed reports of medication errors due to patient allergies and found that lack of patient or drug information contributed to many of these errors.
The Medication Errors Panel. Sacramento, CA: California State Senate; March 2007.
This report shares findings from an expert panel convened to study the causes of medication error in the outpatient setting and provide recommendations for reducing errors associated with prescription and over-the-counter medications.
Legislation/Regulation > Legislation/Case Law
Enacting the Washington state patient safety act requiring hospital staffing plans for nursing services and establishing recordkeeping and reporting requirements.
Washington State Legislature. HB 1602 (2003).
This addition to the Washington Patient Safety Act requires hospitals to develop and implement a staffing plan for nursing services. The plan addresses personnel issues for each patient care unit, requires hospitals to maintain records regarding patients and nursing care personnel, and authorizes the Department of Health to investigate complaints of staffing plan requirement violations and to conduct audits.