Narrow Results Clear All
- Study 3
- Slideset 1
- Book/Report 18
- Legislation/Regulation 6
- Newspaper/Magazine Article 11
- Newsletter/Journal 2
- Special or Theme Issue 4
- Toolkit 3
- Web Resource 17
- Award 1
- Press Release/Announcement 1
- Communication Improvement 13
- Culture of Safety 4
- Education and Training 11
- Error Reporting and Analysis 34
- Human Factors Engineering 2
Legal and Policy Approaches
- Regulation 10
- Logistical Approaches 4
- Quality Improvement Strategies 12
- Specialization of Care 3
- Teamwork 2
- Clinical Information Systems 4
- Transparency and Accountability 2
- Device-related Complications 4
- Diagnostic Errors 3
- Discontinuities, Gaps, and Hand-Off Problems 5
- Fatigue and Sleep Deprivation 1
- Identification Errors 2
- Medical Complications 6
- Medication Safety 9
- Nonsurgical Procedural Complications 1
- Psychological and Social Complications 3
- Surgical Complications 7
- Family Members and Caregivers 2
- Health Care Executives and Administrators 46
Health Care Providers
- Nurses 1
Non-Health Care Professionals
- Media 3
- Patients 11
Search results for "State Governments and Agencies"
- Non-Health Care Professionals
- State Governments and Agencies
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.
Web Resource > Multi-use Website
385B Highland Colony Parkway, Suite 504, Ridgeland, MS 39157.
This collective of local health care organizations is committed to improving patient safety in Mississippi.
Journal Article > Study
Shahian DM, Wolf RE, Iezzoni LI, Kirle L, Normand SL. N Engl J Med. 2010;363:2530-2539.
Hospital-wide mortality rates are widely used as a marker of health care quality, but it remains unclear how to most accurately measure them. In this classic study, investigators provided standard hospital discharge data to four vendors who independently calculated hospital mortality rates. These methods produced varying rates of hospital mortality, and classification of hospitals as either higher or lower than average differed depending on the estimation method. These findings demonstrate that in-hospital mortality remains difficult to estimate and underscore the need for caution in considering it a marker of hospital care quality.
Tools/Toolkit > Toolkit
Elkridge, MD: Maryland Patient Safety Center.
Special or Theme Issue
Pa Patient Saf Advis. June 2010;7(suppl 2):1-16.
Salt Lake City, UT: Utah Department of Health, Utah Hospitals & Health Systems Association, and HealthInsight; March 10, 2010.
This brief provides information on 101 sentinel events reported to the state of Utah in 2009. The report also includes background on efforts to address such incidents.
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.
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.
The High Costs of Weak Compliance With the New York State Hospital Adverse Event Reporting and Tracking System.
Thompson WC Jr. New York, NY: Office of the New York City Comptroller, Office of Policy Management; 2009.
This report assesses the New York State Department of Health's New York Patient Occurrence and Tracking System (NYPORTS). It observes trends of adverse event reporting, finds that New York City hospitals report dramatically fewer events per discharge, explores reasons for underreporting, and discusses the impact on safety improvement efforts.
PA-PSRS Patient Saf Advis. March 2009;6:16-19.
This article discusses strategies to ensure safe transitions for patients between hospital departments. These strategies include transport team development, use of standardized communication tools, and educational programming for unlicensed health care personnel.
Chasson L, compiler; Mahoney G, Sherard BD, eds. Cheyenne, WY: Wyoming Department of Health; 2008.
This report aggregates data on adverse events from July 2007 to June 2008 and analyzes the results of data collected in the 3 years since the Wyoming reporting program began.
St. Paul, MN: Minnesota Department of Health; January 2009.
Through a qualitative evaluation of the Minnesota statewide reporting initiative, this report suggests ways to improve the reporting system to facilitate continued learning and transparency.
PA-PSRS Patient Saf Advis. March 2008;5(suppl rev):1-50.
This failure mode and effects analysis (FMEA) explores factors contributing to near miss and adverse events related to alarm response and provides strategies to prevent monitoring failures.
Saving Lives, Saving Money: The Imperative for Computerized Physician Order Entry in Massachusetts Hospitals.
Adams M, Bates D, Coffman G, Everett W. Westborough, MA: Massachusetts Technology Collaborative and New England Healthcare Institute; 2008.
Analyzing patient charts at six community hospitals in Massachusetts, this report reveals to what extent adopting computerized physician order entry could affect clinical outcomes and impart financial savings.
Graham J. Chicago Tribune. August 21, 2007;Metro section:1.
This article discusses a new Illinois state law that requires hospitals to screen all intensive care patients for methicillin-resistant Staphylococcus aureus (MRSA) infections and to isolate infected patients.
Legislation/Regulation > Pennsylvania Legislation
General Assembly of Pennsylvania. SB968 (2007).
This bill requires that Pennsylvania hospitals and nursing homes implement an internal infection control plan and report hospital-acquired infections.
Legislation/Regulation > New Jersey Legislation
New Jersey Legislature. A4327 (2007).
This bill amends a previous law by requiring that serious preventable adverse events be reported to the New Jersey Department of Health and Senior Services and that a list of these errors and where they occurred be publicly available.
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.
St. Paul, MN: Minnesota Department of Health; January 2009.
This report provides background on the Minnesota Never Events reporting initiative, tips for patients on how to receive the safest care possible, and a table of events reported by all hospitals in the state.
Award > Award Recipient
Rabinowitz ABK, Clarke JR, Marella W, et al. Jt Comm J Qual Patient Saf. 2006;32:676-681.