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- Journal Article 2
- Book/Report 5
- Legislation/Regulation 10
- Newspaper/Magazine Article 3
- Special or Theme Issue 1
- Toolkit 2
- Web Resource 4
- Award 1
- Meeting/Conference 1
- Press Release/Announcement 1
- Communication Improvement 5
- Culture of Safety 2
- Education and Training 5
- Error Reporting and Analysis 12
- Human Factors Engineering 1
Legal and Policy Approaches
- Regulation 15
- Logistical Approaches 1
- Quality Improvement Strategies 6
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- Technologic Approaches 2
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Search results for "State Governments and Agencies"
- Legal and Policy Approaches
- State Governments and Agencies
Legislation/Regulation > Colorado Legislation
Pettersen B, Tate J, Tipper K, McKean H. Colorado Senate Bill 19-201.
Communication-and-resolution mechanisms are seen as important approaches to improving transparency and healing after an adverse event. This state bill, referred to as the "Colorado Candor Act," protects conversations between organizations, clinicians, patient, and families from legal discoverability and outlines criteria to guarantee that protection.
Hendricks R, O'Neil M, Volmert A. Boston, MA: Betsy Lehman Center for Patient Safety; March 2019.
This report suggests that the field of patient safety needs to be reframed for the public. The report recommends that patient safety professionals, experts, and advocates define patient safety, explain the prevalence of medical errors, and describe solutions. The authors emphasize that sharing the systems approach to improvement can help patients understand how patient safety issues can be prevented. They encourage continued use of the aviation metaphor to illustrate why medical errors occur and how to address them. The authors urge patient involvement with a focus on concrete activities, but they recommend avoiding the term "patient empowerment." An Annual Perspective discussed how patient engagement, when done correctly, can help health care systems identify safety hazards, regain trust after they occur, and codesign sustainable solutions.
Journal Article > Commentary
Should medical malpractice prevention be considered separately or as an integral part of comprehensive health care safety improvement?
Enbom JA. Am J Obstet Gynecol. 2013;208:495-498.
Exploring the relationship between liability payments and patient safety, this commentary recommends that the concepts be combined to inform and drive improvement.
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.
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.
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.
The Pennsylvania Learning Exchange: Helping States Improve and Integrate Patient Safety Initiatives—Summary Report.
Hanlon C, Rosenthal J. Washington, DC: National Academy for State Health Policy; 2007.
This report summarizes a September 2007 symposium that brought together patient safety officials from 11 states. The meeting examined existing and emerging issues and also provided participants with policy solutions based on strategies successfully implemented in Pennsylvania.
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.
Award > Award Recipient
Rabinowitz ABK, Clarke JR, Marella W, et al. Jt Comm J Qual Patient Saf. 2006;32:676-681.
Evanston, IL: Office of the Governor; July 13, 2006.
This news release announces the governor's plans to improve patient safety in Illinois, including the use of e-prescribing by all providers and a Division of Patient Safety within the state public health department.
PA-PSRS Patient Saf Advis. March 2006;3:13-19.
This article addresses strategies for minimizing patient safety risks related to interactions with health care industry representatives, as well as the role they can play in promoting safety.
Postman D. The Seattle Times. February 21, 2006:A1.
This article reports on a compromise reached by doctors and lawyers in Washington state. The proposed bill would allow physicians to apologize for mistakes without the apology being used against them in court.
Web Resource > Multi-use Website
New York Department of Health, Empire State Plaza, Albany, NY 12237.
The Center's efforts for patient safety are highlighted, including New York's Patient Occurrence Reporting and Tracking System, Clinical Guideline development, and a state patient safety awards program.
Rosenthal J, Booth M. Portland, ME: National Academy for State Health Policy; November 2004.
Six states have enacted legislation to support the development of state patient safety centers to address the problem of medical errors. This report examines the various models applied in these states to design, administer, and monitor the centers.
Legislation/Regulation > Congressional Testimony
Hearings before the House Insurance Committee of the Pennsylvania General Assembly. (April 22, 2004) (statement of James R. Combes, MD, senior medical advisor, HAP).
This statement introduces the Pennsylvania Patient Safety Reporting System (PA-PSRS), a statewide reporting initiative.
HB 1629 Section 18 Section 381.0271 Florida Statute; 2004.
Established the patient safety center in the state of Florida.
Minnesota State Legislature. SF 1019 (2003).
The law requiring Minnesota hospitals to report on a defined set of serious events.