Narrow Results Clear All
- WebM&M Cases 1
- Perspectives on Safety 1
- Journal Article 2
- Slideset 1
- Book/Report 14
- Legislation/Regulation 2
- Newspaper/Magazine Article 35
- Special or Theme Issue 1
- Tools/Toolkit 1
- Web Resource 8
- Communication Improvement 9
- Culture of Safety 8
- Education and Training 5
Error Reporting and Analysis
- Error Reporting 19
- Human Factors Engineering 4
Legal and Policy Approaches
- Regulation 17
- Logistical Approaches 1
- Quality Improvement Strategies 17
- Specialization of Care 1
- Technologic Approaches 2
- Transparency and Accountability 1
- Device-related Complications 4
- Diagnostic Errors 3
- Discontinuities, Gaps, and Hand-Off Problems 4
- Drug shortages 1
- Fatigue and Sleep Deprivation 1
- Identification Errors 1
- Medical Complications 9
- Medication Safety 11
- Nonsurgical Procedural Complications 1
- Surgical Complications 12
- Transfusion Complications 1
- Internal Medicine 25
- Nursing 2
- Pharmacy 1
- Family Members and Caregivers 2
- Health Care Executives and Administrators 40
Health Care Providers
- Nurses 2
Non-Health Care Professionals
- Media 4
- Australia and New Zealand 1
- Europe 5
- North America 52
Search results for "Hospitals"
Kowalczyk L. The Boston Globe. December 22, 2005.
This article reports on several hospitals in Massachusetts that continue to perform obesity surgeries, despite falling short of the recommended number of operations per year to meet voluntary patient safety guidelines.
Weise E. USA Today. May 18, 2005.
Rein L. Washington Post. August 30, 2019.
Appleby J, Lucas E. Kaiser Health News. August 14, 2019.
Gordon M. Health Shots. National Public Radio. April 10, 2019.
Punitive responses to medical errors persist despite continued efforts to reduce them. This news article reports on an incident involving the mistaken use of a neuromuscular blocking agent that resulted in the death of a patient, the prosecution of the nurse who made the error, and systemic and human factors that contribute to similar events.
Rau J. Kaiser Health News. March 1, 2019.
Financial incentives may encourage adoption of practice improvements that enhance safety. This news article reports on the increase in United States hospitals that have had Medicare payments withheld due to high rates of hospital-acquired conditions. The article is accompanied by a state-level tally of individual hospitals penalized.
Biel L. ProPublica. October 2, 2018.
This news article reports on systemic weaknesses that enabled a surgeon with poor skills to continue to perform procedures after numerous surgical errors that resulted in patient harm. A past PSNet perspective explored the risk of recurring medicolegal events among providers who have received unsolicited patient complaints, faced disciplinary actions by medical boards, or accumulated malpractice claims.
Ghaferi AA, Myers C, Sutcliffe KM, Pronovost PJ. Harv Bus Rev. July/August 2016;94.
Achieving high reliability is a recognized goal for health care organizations. Reviewing current technical and standardization enhancements to augment quality and safety in surgery, this article explores how implementing high reliability concepts could further improve safety in surgical care over time.
Landro L. Wall Street Journal. May 9, 2016.
Closed claims have been considered a source for adverse event data for years, and recently such data has been utilized to inform safety improvement work. This newspaper article reviews several organizational efforts that use claims data to determine factors that contribute to failure and strategies to address them, including process redesign and enhanced patient education.
Rice S. Mod Healthc. 2014;44:16-18, 20.
Language barriers can lead to misunderstandings that increase risks of error. This magazine article highlights the frequent reliance on families, friends, and other nonprofessionals as translators in medical settings and discusses how lack of standards and insufficient reporting of errors related to interpreters, along with challenges to implementing programs, hinder progress in improving communication with non-English speaking patients.
Flatten M. Washington Examiner. August 18–22, 2014.
Clark C. HealthLeaders Media. August 7, 2014.
Although California has collected an estimated $15 million in penalties from hospitals for adverse events, this news piece describes how much of the money has yet to be allocated or spent on safety improvement projects. Moreover, some state agencies have been reluctant to provide specific data to projects that have already been funded.
Department of Health. London, England: Crown Publishing; November 2013. ISBN: 9780101875424.
This report outlines actions that health care leaders in the United Kingdom have committed to take in order to address system problems identified by an inquiry into Mid Staffordshire National Health Services Foundation Trust.
Rensselaer, NY: Healthcare Association of New York State; October 2013.
This publication assessed 10 widely disseminated hospital report cards by criteria including transparency of methodology, evidence-based measures, and data quality. While inconsistent methods across reports hindered direct comparisons, a few reports received high marks.
Oakbrook Terrace, IL: The Joint Commission; October 2013.
This Joint Commission report summarizes the performance of hospitals across 47 accountability measures—evidence-based metrics that are directly linked to patient outcomes. This year's calculation for identifying Top Performers included a new accountability measure for immunization. Top Performers are recognized by meeting three 95% performance thresholds; 1099 hospitals were identified. This represents 33% of all Joint Commission-accredited hospitals that report core measure performance data, a 77% increase compared to the previous year. Hospitals have measurably improved the quality of care over the past year for heart attacks, pneumonia, surgical care, children's asthma care, inpatient psychiatric services, venous thromboembolism, and stroke patients.
Tools/Toolkit > Measurement Tool/Indicator
This Web site provides resources to help employers and purchasers estimate latent costs related to unsafe care.
Chen PW. New York Times. April 18, 2013.
Sanghavi D. Boston Globe Magazine. January 27, 2013.
Web Resource > Government Resource
National Patient Safety Agency.
This Web site provides data on safety incidents from the United Kingdom in the form of workbooks sorted by either organization or region.
Cooper JJ. ABC News. July 12, 2012.
This news article reports on how drug shortages have affected emergency medical services.