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- Communication Improvement 15
- Culture of Safety 4
- Education and Training 5
Error Reporting and Analysis
- Error Reporting 17
- Human Factors Engineering 6
- Legal and Policy Approaches 16
- Logistical Approaches 1
- Quality Improvement Strategies 9
- Teamwork 2
- Technologic Approaches 3
- Transparency and Accountability 1
- Device-related Complications 3
- Identification Errors 22
- Medical Complications 8
- Medication Safety 4
- Nonsurgical Procedural Complications 1
- Psychological and Social Complications 4
- Surgical Complications
Search results for "Patients"
- Intraoperative Complications
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.
Web Resource > Government Resource
Centers for Medicare & Medicaid Services.
The Centers for Medicare and Medicaid Services (CMS) provides consumers with publicly available information on the quality of Medicare-certified hospital care through this Web site. The site includes specific information for both patients and hospitals on how to use the data to guide decision-making and improvement initiatives. Most recently, listings from the Hospital-Acquired Condition Reduction Program (HACRP) and data on Department of Veterans Affairs hospitals were added to the reports available.
Grant T. Washington Post. July 22, 2008:HE01
This article reports on a wrong-sided surgery near miss from the perspective of a parent, and discusses the role of family members in preventing medical errors.
Gulliver D. Herald Tribune. September 3, 2007.
This article describes how the culture around medical errors is evolving to include disclosure and transparency, illustrated by a physician's willingness to discuss a wrong-site surgery.
Cohen E. CNN. March 24, 2016.
Poor communication regarding medical errors can contribute to patient and family frustration and fear. Reporting on a case involving disclosure of a wrong-site surgery, this news article describes a resolution program to help patients cope after a preventable error. The program includes apology, disclosure, and explanation of what occurred as well as financial compensation.
Luthra S. Kaiser Health News. July 14, 2015.
O'Donnell J. USA Today. August 6, 2014.
This newspaper article reports on changes to publicly reported data on the Hospital Compare Web site. Several avoidable hospital-acquired conditions, such as air embolism or retained foreign objects, are no longer included. Working with the National Quality Forum, the Centers for Medicare and Medicaid Services (CMS) decided to modify the list to make it easier for consumers to use and understand.
Hamblin J. The Atlantic. March 17, 2014.
Reporting on the use of checklists, this magazine article describes studies that identified benefits, such as reduced complication rates, along with research that questioned the effectiveness of checklists in improving safety. The article also discusses how these assessments may influence checklist application in health care over time.
Natt TM Jr. The Pilot. August 9, 2013.
This news article reports how a hospital was placed on "immediate jeopardy" status and revised its policy for fire safety in the operating room after a patient was injured during a surgical fire.
Ryan J. KUOW. National Public Radio. August 1, 2013.
Eisler P. USA Today. March 8, 2013.
Messina I. Toledo Blade. August 24, 2012.
This newspaper article discusses an incident in which a transplant organ was mistakenly discarded.
Miller R. News-Times. July 25, 2012.
This newspaper article details the complications and errors a patient experienced following a routine surgery.
Hopperstad J. KCPQ-TV. December 5, 2011.
This news feature reports on an incident of surgical fire and its impact on the patient.
Boodman SG. Washington Post. June 21, 2011:E1.
Rojas-Burke J. The Oregonian. May 25, 2011.
Bernhard B, Kohler J. St. Louis Post-Dispatch. August 1, 2010:A1
In the context of system failures that contributed to the death of a patient, this newspaper article describes how never events are rarely publicized, even though hospital inspection reports are public records.
Stein L. St. Petersburg Times. June 21, 2010.
Reporting on wrong-site surgeries in Florida hospitals, this newspaper article describes how timeouts have changed the nature and frequency of surgical errors.
Cohen E. Empowered Patient. CNN.com. November 13, 2009.
This news story describes an incident of patient misidentification and offers tips to help patients confirm their care during a hospitalization.
Hoffman M. Military Times. July 30, 2009.
This news article on a surgical mistake illustrates the compounded impact of medical error on patients and their families.