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- Patient Safety Primers 1
- WebM&M Cases 6
- Perspectives on Safety 4
- Commentary 19
- Review 4
- Study 31
- Slideset 1
- Book/Report 58
- Legislation/Regulation 4
- Newspaper/Magazine Article 400
- Newsletter/Journal 1
- Special or Theme Issue 5
- Glossary 1
- Toolkit 9
- Web Resource 61
- Award 3
- Meeting/Conference 3
- Press Release/Announcement 4
Communication between Providers
- Sbar 1
- Communication between Providers 50
- Culture of Safety 44
Education and Training
- Students 2
Error Reporting and Analysis
- Never Events 11
- Error Reporting 137
Human Factors Engineering
- Checklists 24
Legal and Policy Approaches
- Regulation 30
- Logistical Approaches 34
- Policies and Operations 5
Quality Improvement Strategies
- Benchmarking 15
- Research Directions 2
- Specialization of Care 23
- Teamwork 14
- Clinical Information Systems 35
- Transparency and Accountability 11
- Alert fatigue 3
- Device-related Complications 36
- Diagnostic Errors 52
- Discontinuities, Gaps, and Hand-Off Problems 56
- Drug shortages 5
- Failure to rescue 3
- Fatigue and Sleep Deprivation 15
- Identification Errors 39
- Interruptions and distractions 3
- Delirium 1
- Medication Errors/Preventable Adverse Drug Events 57
- Nonsurgical Procedural Complications 15
- Overtreatment 3
- Psychological and Social Complications 39
- Surgical Complications 128
- Transfusion Complications 4
- Ambulatory Care 44
- General Hospitals 176
- Long-Term Care 5
- Outpatient Surgery 11
- Patient Transport 2
- Psychiatric Facilities 3
- Allied Health Services 1
- Internal Medicine 198
- Obstetrics 17
- Pediatrics 39
- Radiology 11
- Nursing 20
- Palliative Care 2
- Pharmacy 25
- Family Members and Caregivers 52
- Health Care Executives and Administrators 202
Health Care Providers
- Nurses 25
- Physicians 52
Non-Health Care Professionals
- Educators 15
- Media 11
- Australia and New Zealand 5
- Europe 43
- Canada 14
United States of America
United States Federal Government
- Department of Health and Human Services (HHS) 23
- United States Federal Government 27
Search results for "Hospitals"
Cases & Commentaries
- Web M&M
Dean Schillinger, MD; March 2004
A misunderstanding of instructions on how to administer medication leads to an infant choking on a syringe cap.
Bosk CL. Chicago, IL: University of Chicago Press; 2003. ISBN: 0226066789.
In this seminal study, Bosk, a medical sociologist at the University of Pennsylvania, spent a year observing the surgical residents and faculty at an unnamed hospital, in the process exploring the balance between autonomy and oversight in medical training, how physicians deal with their errors, and the nature of accountability in the medical profession. This edition, published more than two decades after Forgive and Remember was first published, includes a new prologue, epilogue, and list of appendices. The book is informative for both lay readers and clinicians.
Tools/Toolkit > Fact Sheet/FAQs
Chicago, IL: National Patient Safety Foundation.
Postoperative infections represent a common and often preventable event. This patient fact sheet outlines practical tips to minimize risk.
Tools/Toolkit > Fact Sheet/FAQs
McLean, VA: National Patient Safety Foundation.
A review of steps for patients to make their transition home as safe as possible.
Legislation/Regulation > Multi-use Website
The Joint Commission.
According to an AHRQ-supported study, wrong-site surgery occurred at a rate of approximately 1 per 113,000 operations between 1985 and 2004. In July 2004, The Joint Commission enacted a Universal Protocol that was developed through expert consensus on principles and steps for preventing wrong-site, wrong-procedure, and wrong-person surgery. The Universal Protocol applies to all accredited hospitals, ambulatory care, and office-based surgery facilities. The protocol requires performing a time out prior to beginning surgery, a practice that has been shown to improve teamwork and decrease the overall risk of wrong-site surgery. This Web site includes a number of resources and facts related to the Universal Protocol. Wrong-site, wrong-procedure, and wrong-patient errors are all now considered never events by the National Quality Forum and sentinel events by The Joint Commission. The Centers for Medicare and Medicaid Services have not reimbursed for any costs associated with these surgical errors since 2009.
Gawande A. New York, NY: Metropolitan Books; 2002. ISBN: 0805063196.
In Complications, Gawande reprises and builds on a series of feature articles, several written for the New Yorker during his surgical residency at Harvard, exploring the imperfect science of medicine. Part I, Fallibility, explores several patient safety issues. Part II, Mysteries, presents a series of remarkable cases that perplex even the most seasoned clinicians. Lastly, Uncertainty explores the common situations in medicine in which even highly trained physicians are required to act with imperfect knowledge. Written for both practitioners and patients, Complications effectively opens up the fascinating, previously hidden world of surgery to its readers.
Altman LK. New York Times. December 11, 2001;1:1.
This news piece reports on wrong-site and wrong-patient surgery and describes efforts to prevent surgical errors following a Joint Commission sentinel event alert on the topic.
Journal Article > Commentary
Delbanco T, Berwick DM, Boufford JI, et al. Health Expect. 2001;4:144-150.
This viewpoint presents a summary of recommendations from the 1998 Salzburg Seminar entitled “Through the Patient’s Eyes.” The purpose of this seminar series is to offer a neutral forum for discussing beliefs on a variety of topics. The 5-day seminar was attended by 64 individuals from 29 different countries with a mission to create a health care system for a mythical republic called PeoplePower. The premise builds on a principle of “nothing about me without me,” as teams of health professionals, patient advocates, artists, reporters, and social scientists established a conceptual model. The authors share the participants’ visions of an ideal clinician-patient relationship and the role hospitals, national and local governmental agencies, and communities play in supporting such a model. Although they conclude that their health care system remains detached from financial, historical, and societal restraints, the principles serve as reminders that health programs must draw closer together patients and those who care for them.
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.
Zipperer LA, Cushman S, eds. Chicago, IL: National Patient Safety Foundation; 2001. ISBN: 1579471889.
The editors present eight chapters covering key areas of patient safety: epidemiology of error, reporting of error, lessons from anesthesiology, emotional response to error, human factors, medication error, and general studies of error and administrative issues.
Audiovisual > Audiovisual Presentation
Producer: Partnership for Patient Safety & Risk Management Foundation. Chicago, IL: Partnership for Patient Safety; 2000.
This video, produced by the Partnership for Patient Safety and the Harvard Risk Management Foundation, presents a series of missteps involving a healthy obstetric patient and her unborn infant. Based on actual facts drawn from the experience of the Risk Management Foundation of the Harvard Medical Institutions, this 18-minute film illustrates the value of having a systems awareness in medicine. Deeper explorations of teamwork, hand-offs, communication skills, and managing the authority gradient provide rich examples for viewers. Parts 2 and 3 complete the video series.
van Vuuren W. [dissertation]. Eindhoven, The Netherlands: Eindhoven University of Technology; 1998.
This report provides a detailed review of risk management in complex and high-risk organizations. The author focuses on the analysis and categorization of safety-related incidents and their organizational causes.
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.
The Girl Who Died Twice: Every Patient's Nightmare: the Libby Zion Case and the Hidden Hazards of Hospitals.
Robins NS. New York, NY: Delacorte Press; 1995. ISBN 0385308094.
Robins, an investigative journalist, recounts the story of Libby Zion, who died at New York Hospital in 1984 allegedly at the hands of under-supervised and overworked residents. The book is an interesting and engaging account of a case and its aftermath, including the highly publicized malpractice trial and the formation of the Bell Commission, which regulated resident work-hours for the first time. The book provides an important historical context for this case and the debate surrounding it, the implications of which are still being felt today in the wake of national regulations for resident duty-hours.