Narrow Results Clear All
- Communication Improvement 2
- Culture of Safety 6
- Education and Training 1
- Error Reporting and Analysis 8
- Human Factors Engineering 2
- Legal and Policy Approaches 8
- Policies and Operations 1
- Quality Improvement Strategies 8
- Specialization of Care 2
- Teamwork 1
- Technologic Approaches 1
- Device-related Complications 3
- Medical Complications 7
- Medication Safety 6
- Nonsurgical Procedural Complications 1
- Surgical Complications 6
Search results for "Medicine"
Journal Article > Commentary
Mazer BL, Nabhan C. J Gen Intern Med. 2019 Jul 10; [Epub ahead of print].
Washington, DC: Department of Veterans Affairs, Office of Inspector General. March 7, 2018. Report No. 17-02644-130.
Systemic weaknesses in the Veterans Affairs health system have resulted in high-profile failures. Highlighting concerns at one medical center that were found to contribute to opportunities for waste, fraud, and poor health care delivery, this report by the Office of Inspector General outlines 40 recommendations to address deficiencies.
Joint Commission. January 27, 2014.
The Eisenberg Award honors individuals and organizations who have made vital accomplishments in improving patient and quality. The 2013 honorees are Institute for Clinical Systems Improvement, Minnesota Hospital Association, and Stratis Health, from Minnesota; Anthem Blue Cross, National Health Foundation, Hospital Association of Southern California, Hospital Association of San Diego & Imperial Counties, and the Hospital Council of Northern & Central California, from California; Vidant Health, of North Carolina; and Gail L. Warden, in Michigan. The awards were presented at the National Quality Forum's Annual Conference on February 13, 2014, in Washington, DC.
This Web site summarizes patient safety improvement efforts in Tennessee and provides access to an annual report of their efforts and a calendar of training opportunities.
Clark C. HealthLeaders Media. September 13, 2013.
This news piece highlights concern around the safety of elective premature deliveries and describes techniques organizations have used to prevent such procedures.
Web Resource > Multi-use Website
PaSQ Coordinating Secretariat. HAS, Haute Autorité de Santé. La Plaine Saint-Denis Cedex, France.
This organization aims to promote implementation of recommended patient safety practices in European Union member states with a goal of developing a collaborative network to ensure long-term safety and quality improvement.
Tallahassee, FL: Florida Hospital Association; August 2013.
Web Resource > Government Resource
Division of Licensing and Regulatory Services, Maine Department of Health and Human Services.
This Web site provides information about Maine's statewide incident reporting initiative and includes annual sentinel event reports.
Joint Commission. February 6, 2013.
The Eisenberg Award honors individuals and organizations who have made vital accomplishments in improving patient and quality. The 2012 honorees are Saul Weingart, MD, PhD; Kaiser Permanente, Oakland, California; and Memorial Hermann Healthcare System, Houston, Texas. The awards will be presented at the National Quality Forum's Annual Conference on March 8, 2013, in Washington, DC.
Rau J. Kaiser Health News. October 17, 2011.
The Centers for Medicare & Medicaid Services (CMS) published data on hospital-acquired conditions in a 2011 report. This news article discusses new data available on the Hospital Compare Web site, including preventable complications and certain types of medical errors.
Austin, TX: Texas Medical Institute for Technology and the Quaid Foundation; 2010.
This documentary reports on families affected by medical errors; it includes the story of a high-profile heparin overdose and how it transformed the family of actor Dennis Quaid into advocates for patient safety.
Rockville, MD: Agency for Healthcare Research and Quality.
In this annual publication, AHRQ reviews the results of the National Healthcare Quality Report and National Healthcare Disparities Report. Providing a 5-year update on the National Quality Strategy, this report highlights that a wide range of quality measures have shown improvement in quality, access, and cost.
Journal Article > Study
de Saint Maurice G, Auroy Y, Vincent C, Amalberti R. Qual Saf Health Care. 2010;19:327-331.
This study tracked adoption of a process-oriented safety rule and found that compliance eroded over time, with a major trigger being lack of compliance by a senior staff member. The authors provide caution about the role of policies to promote safety behaviors, particularly if such policies are not prioritized by staff as important.
Washington, DC: Leapfrog Group; December 4, 2009.
This news announcement highlights the 45 urban, children's, and rural hospitals recognized for highly efficient performance and continuous improvement in patient safety based on the 2009 Leapfrog Hospital Survey results.
Dr Foster Intelligence Unit. London, UK: Imperial College London; 2009.
This consumer-focused report ranked the 148 hospital trusts in the United Kingdom National Health Service (NHS) on patient safety, clinical effectiveness, and patient experiences and found wide variation in the scores.
Scobie S, Minghella E, Dale C, Thomson R, Lelliott P, Hill K. London, UK: National Patient Safety Agency; July 2006.
This report, the second in a series from the United Kingdom's National Patient Safety Agency, analyzes nearly 45,000 patient safety incidents relating to mental health that were reported to a nationwide incident reporting system. The majority of reported incidents were from inpatient mental health facilities, primarily involving patient accidents (including falls), disruptive or aggressive behavior, self-harming behavior, and missing (absconding) patients. The report summarizes existing initiatives to improve patient safety in mental health, makes specific recommendations for mental health providers, and identifies priority areas for future research.
Journal Article > Study
Stebbing C, Kaushal R, Bates DW. Pediatrics. 2006;117:1907-1914.
This study analyzed newspaper coverage of pediatric medication errors and adverse drug events in five countries to demonstrate increased interest in the topic over the past decade. Investigators examined the number of articles and the types of events covered and assessed the overall themes presented and framed by the media. The majority of articles published covered patient incidents followed by policy and then research in decreasing order of frequency. Despite the occasional occurrence of sensational reporting on errors, more than 70% of articles that were deemed to be negatively associated with patient safety were covered in a neutral manner.
Perspectives on Safety > Perspective
Organizational Change in the Face of Highly Public Errors—I. The Dana-Farber Cancer Institute Experience
with commentary by James B. Conway; Saul N. Weingart, MD, PhD, Errors in the Media and Organizational Change, May 2005
A decade ago, two tragic medical errors rocked one of the world’s great cancer hospitals, Dana-Farber Cancer Institute (DFCI) in Boston, to its core. The errors led to considerable soul searching and, ultimately, a major change in institutional practices a...
Doctor’s orders killed cancer patient: Dana-Farber admits drug overdose caused death of Globe columnist, damage to second woman.
Knox RA. The Boston Globe. March 23, 1995; Metro/Region section: 1.
This column chronicles the tragic death of Betsy Lehman, a Boston Globe health columnist, who fell victim to an inadvertent overdose of chemotherapy while receiving treatment for breast cancer at the Dana-Farber Cancer Institute. The story details the events surrounding the case, the reactions among family and the public, and the response from Dana-Farber.