Narrow Results Clear All
- Communication Improvement 2
- Culture of Safety 3
- Education and Training 3
- Error Reporting and Analysis
Legal and Policy Approaches
- Quality Improvement Strategies 5
- Technologic Approaches 2
- Device-related Complications 1
- Identification Errors 2
- Medical Complications 4
- Medication Safety 2
- Psychological and Social Complications 1
- Surgical Complications 3
Search results for "Regulation"
Rozovsky FA, Woods JR Jr, eds. San Francisco, CA: Jossey Bass; 2011. ISBN: 9781118086995.
This well-referenced and up-to-date handbook covers many of the regulatory and operational issues relevant to developing an organizational patient safety program. It is particularly strong in the areas of regulatory compliance, error reporting, and disclosure. Patient safety officers and risk managers are likely to find it of considerable interest.
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.
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; 2011. ISBN: 9780982842188.
The National Quality Forum originally defined 27 health care "never events"—patient safety events that pose serious harm to patients, but should be considered preventable—in 2002. The 2011 update now consists of 29 events, organized into surgical events (e.g., wrong-site surgery), device events (e.g., air embolism), care management events (e.g., death or disability due to medication errors), patient protection events (e.g., patient suicide), environmental events (e.g., fires), radiologic events, and criminal events. One notable addition to the original list is that serious harm associated with failure to properly follow up on test results is now considered a never event. Since the development and dissemination of this list, many states have mandated that health care facilities report all instances of these events. When such an event occurs, many institutions mandate performance of a root cause analysis.
Opportunities and Recommendations for State–Federal Coordination to Improve Health System Performance: A Focus on Patient Safety.
Buxbaum J. Portland, ME: National Academy for State Health Policy; January 2010.
This briefing summarizes recommendations from a roundtable of health policy leaders, who selected the following areas as foci for initial federal–state coordination of safety efforts: reducing health care–associated infections, decreasing preventable hospital readmissions, and minimizing hospitalization for ambulatory conditions.
Jewell K, McGiffert L. Austin, TX: Consumers Union; 2009.
The 10 years since the release of the Institute of Medicine's To Err Is Human report have yielded some improvements in patient safety, but this Consumers Union report reminds clinicians and consumers alike that much work remains to be done. As the report notes, preventable safety problems such as medication errors and health care–associated infections still cause significant morbidity and mortality, despite the existence of effective preventive strategies. The report advocates for standardized measurement and public reporting of errors and calls for tighter accreditation standards for health care professionals.
National Patient Safety Agency. London, UK: National Reporting and Learning Service; 2009.
This report from the United Kingdom is intended to guide Primary Care Trusts in implementing never events policies for 2009-2010.
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; December 2008. Report No. OEI-06-07-00470.
The Tax Relief and Health Care Act of 2006 mandated that the Office of Inspector General (OIG) report to Congress the incidence of "never events" among Medicare beneficiaries, payment by Medicare for services in connection with such events, and the process used to identify events and deny payments. This report addresses that mandate by providing a descriptive analysis of the key issues to understanding hospital-based adverse events. The report is focused around discussion of seven critical issues that are explored in detail. Of note, OIG expanded the study of never events to the broader topic of adverse events in their analysis.
London, UK: National Patient Safety Agency; 2007. ISBN: 9780955634093.
This report shares the results of the British National Patient Safety Agency effort to reduce medical error and found that safety wasn't always given the priority necessary to drive change and that data collection efforts could still be improved.
Callender AN, Hastings DA, Hemsley MC, Morris L, Peregrine MW. Washington, DC: US Department of Health and Human Services Office of the Inspector General; June 29, 2007.
This report outlines the fiduciary and corporate responsibilities of board members to support quality and safety in hospitals and provides questions to help them examine the scope of these efforts in their organizations.
Office of the Inspector General. Washington, DC: US Department of Health and Human Services; September 2006. Report No. OEI-09-04-00350.
This report presents findings from an investigation into the reporting of and response to restraint and seclusion-related deaths.
Amori G. Chicago, IL: American Society for Healthcare Risk Management; 2006.
This booklet shares scenarios and strategies for effective communication during disclosure of adverse events.
Learning from Bristol: The Report of the Public Inquiry into Children's Heart Surgery at the Bristol Royal Infirmary 1984–1995.
London, England: The Stationery Office; July 2001.
In June 1998, the Secretary for Health announced to Parliament the organization of a formal Inquiry into children's heart surgery at the Bristol Royal Infirmary between 1984 and 1995. Their objectives included understanding what happened in Bristol, assessing the quality of care and system failures that contributed to deaths, and generating lessons that could be learned for the entire National Health Service (NHS) in the United Kingdom. The inquiry was independent and not held as a legal proceeding, but provided a comprehensive investigation with interviews, expert panels, and a goal of driving improvement efforts. Section one of the report outlines pediatric cardiac surgical services in Bristol while section two focuses on recommendations to ensure high quality care across the NHS. Several publications resulted from the learnings of the Bristol inquiry, including a discussion of cultural entrapment and lessons for quality improvement.