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- Discontinuities, Gaps, and Hand-Off Problems 2
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- Medication Safety 1
Search results for "Audit and Feedback"
- Audit and Feedback
- Governmental Reporting
Jefferson City, MO: Center for Patient Safety; June 11, 2019.
Patient Safety Organizations (PSOs) provide local evidence to inform learning at the state level. This annual report analyzes trends present in reports submitted to the PSO in 2018. Medication errors, falls, and health care–acquired infections were frequently reported. The material discusses reasons for these events, shares lessons learned, and points to resources to aid organizations in reducing conditions that enable reportable occurrences.
Healthcare Inspection: Evaluation of the Veterans Health Administration's National Consult Delay Review and Associated Fact Sheet.
Daigh JD Jr. Washington, DC: VA Office of the Inspector General; December 15, 2014. Report No. 14-04705-62.
Misrepresentation of findings, either by accident or design, can result in ineffective use of resources and poor decision-making. This investigation found inconsistencies in the information reported by the Veterans Health Administration in the widely-publicized analysis discussing weaknesses in the organization that resulted in delayed care. The author calls for the assessment to be revisited to ensure conclusions and work toward improvement are verifiable to augment the safety and timeliness of care provided to veterans.
Journal Article > Study
Greene SB, Williams CE, Pierson S, Hansen RA, Carey TS. J Patient Saf. 2011;7:92-98.
All North Carolina nursing homes are required to report medication error data. This study reports on a pilot effort to feed back data on error rates to individual nursing homes.
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.
Gould M. Health Service Journal. September 15, 2008:22-24.
This article describes the state of general practitioner incident reporting in the United Kingdom.
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.
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.